E-ISSN:2456-3110

Review Article

pathogenesis

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 10 October
Publisherwww.maharshicharaka.in

Ayurvedic understanding of pathogenesis of Psoriasis in general

Moon R1*, Diggavi M2
DOI:10.21760/jaims.8.10.21

1* Rakhi Moon, 2nd Year Post Graduate Scholar, Department Of Kaya Chikitsa, Taranath Government Ayurvedic Medical College, Bellary, Karnataka, India.

2 Madhava Diggavi, Professor and HOD, Department of Kaya Chikitsa Taranath, Government Ayurvedic Medical College, Bellary, Karnataka, India.

Psoriasis is an autoimmune, complex, multifactorial, non-infectious, chronic inflammatory relapsing skin disease characterized by erythematous plaques with silvery scales. Prevalence of the disease world-wide ranges from 0.09% to 11.4% of the total population. According to WHO, at least 100 million individuals suffer from psoriasis worldwide with a great negative impact on the quality of life. Immuno chemistry and auto immunity are well developed to explain changes in cell biology in case of psoriasis. Ayurveda has good success rate in the management of psoriasis. But to answer the query regarding pathogenesis of psoriasis as per ayurveda is not yet clear. Hence in the present paper an effort is made to understand the pathogenesis of psoriasis on par with current trends in psoriasis.

Keywords: Psoriasis, Kushta, Ayurveda

Corresponding Author How to Cite this Article To Browse
Rakhi Moon, 2nd Year Post Graduate Scholar, Department Of Kaya Chikitsa, Taranath Government Ayurvedic Medical College, Bellary, Karnataka, India.
Email: 		Moon R, Diggavi M, Ayurvedic understanding of pathogenesis of Psoriasis in general. J Ayu Int Med Sci. 2023;8(10):143-148.
Available From
https://jaims.in/jaims/article/view/2823

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-08-12 2023-08-28 2023-08-03 2023-09-08 2023-09-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 18.90%

© 2023by Moon R, Diggavi Mand 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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Introduction

Skin is the largest organ in the body and barrier between body’s internal environment and the cosmos. As it provides physical permeability barrier, UV protection, sensation, wound repair and regeneration. In Ayurveda it is one among five Gyanendriya’s responsible for ‘Sparsha Gyan’. Psoriasis is an autoimmune non-infectious hyperproliferative chronic inflammatory relapsing skin disease characterized by well demarcated erythematous plaques with silvery scales[1] having prevalence range between 0.09% to 11.4% of the total population. According to WHO 100 million individuals suffer from psoriasis world-wide with great negative impact on quality of life.[2] Psoriasis can affect all age groups, mainly the ages of 20 and 30 and between the ages 50 and 60.[3] In ayurveda classical text a separate chapter are mentioned as Kushta Roga with separate aetiology, pathogenesis and management.

Various skin disease comes under Kushta classified as 7 Maha Kushta and 11 Kshudra Kushta.[4] ‘Kushtani Vapuhu Iti Kushta’[4] means which makes skin disgraceful and ugly which destroys Twak and other Dhatus is called Kushta. Due to Mithya Ahara, Vihara and Papa Karma, Tridosha Dusti, Rasa, Rakta, Mamsa, Lasika and Majja Dusti takes place considered as Saptha Dravya Sangraha.[5] Person’s life with psoriasis may trigger with reoccurrence, unpredictable and severity in one episode to another. In current scenario, food habits and daily life style of person due to busy schedule has been changed. With these persons mental health disturbed, it effects and leads to the psychological stress, depression as independent factor of psoriasis.

Objectives

To understand the pathology of Psoriasis in Ayurveda with an integrated approach based on current dermato immunochemistry.

Material and Methods

Etiology of Psoriasis/Kushta

Genetic Factors

Having a family member with the disease increases the risk factor. One of the parent has psoriasis,

there is 10% chance of getting it. On other side if two parents with history risk is 50% clear.[6] There is an incidence was found much greater amongst 1st and 2nd degree relative of a patient with psoriasis.[7] Psoriasis has been associated with many human leukocyte antigen haplotypes (HLA), CW6 and 9 candidate loci have been identified by using linkage analysis and genome wide association study’s.[8] Pre disposing polygene might affect the immune system or be involved in keratinocyte differentiation. There has also been a report of an association of psoriasis with variant alleles of lymphoid phosphatase PTPN22.[9]

Kulaja Nidana

Kushta is considered as Adibala Pravruttavyadhi[10] i.e., a hereditary disorder, if both mother and father are having Kushta, the offspring also may become victim of Kushta as it is Rakta Pradoshaja Vikara.

Purvajanmakrita

According to Sushruta if the person suffered from Kushta in his previous life and if he takes rebirth then he develops Kushta in his present life also.[11]

Diet

Diet plays a role in aetiology and pathogeneses of psoriasis like dairy products and fish items etc. it’s observed that 60% of patients changing their dietary habits, low energy diets and vegetarian diets improved psoriasis symptoms in some studies.

[12]

Janmottarakalaja

It is categorized in Aharaja - diet and dietetic pattern and Viharaj - improper physical, verbal and mental activities.

Aharaja Nidana

1. Atisevan: Taking excessive Guru, Snigdha Bhojana like new formed rice, heavy for digestion foods, she buffaloes milk, curd, fish, jaggery, food articles prepared by sugars and carbohydrate rich foods, this all produces Dushti in Rasavaha Srotas and Mamsavaha Srotas.[13] thus, can be consider Atimatra Ahara leads to Amotpatti which further leads to Kushta disease.

2. Vishamashana: Taking food in improper time and improper quantity leads to Vishama Agni which makes it part in etiology in Kushta. In present day life people with busy schedule facing the problem due to no time to eat properly and healthy diet.


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3. Ajirnashana: Intake of food in state of indigestion is Ajirnashana causes Agnimandhya and Malavaha Srotas Dhusti which ultimately leads to disease. According to Acharya Charaka, taking food in state of indigestion is best known to cause Grahani Dushti[14] leads to impairment in normal physiological function of Grahani, this pathology continuous for long time produces Kushta Roga.

4. Viruddha Ahara: Like milk with fish i.e., Samyoga Viruddha disturbed the function of Agni and Srotas results in indigestion further leads to sour and acts like poison called Amavisha, Tridosha get triggered by this Amavisha. In case of Srotas effect the vitiation leads to Srotas Dushti i.e., malfunctioning of Srotas and form Atipravrutti, Sanga, Siragranthi and Vimarga Gaman Srotodusti type.[15]

5. Mithyaaahara: There are certain codes of conducts of eating which when not followed are called Mityaahara. The codes of conduct of eating have been termed as Ashta Aharavidhi Vishesh Ayatana and Dwadashaashanavidhi. Over ruled these codes disturbs the Agni and produces Ama which in turn produces Amavisha.[16] so along with Kushta other disease occurs which can manifest due to Ama, Amavisha may coexist. like psoriasis, the coexistence of psoriatic arthritis, Crohn disease dermatogenic enteropathy have been reported.

Viharaja Nidana

Physical activities like suppressing the natural urges like Chardi Vegadharana, day sleep, sexual intercourse, excessive exposure to sunrays, hot and humid environment, over exercise. Sheetodaka Sevana after Shrma, Brama, Bhaya, Santapa and also due to error in Panchakarma therapy’s like Sthambana in Raktarsha, Sneha Vyapat, Sthambana in Amatisara.[17] Verbal sinful activities like abusing teacher, the factor brings out psychogenic stress which plays role in Kushta. Chinta, Bhaya, Shoka are Vata Prakopaka and Swedovaha Srotodrushti Nidana.[18]

Psychological Factors

Psych cutaneous medicine impacts on the interaction between mind, brain and skin. The brain and skin originate from same germ layers i.e., the embryonic ectoderm and are under the influence of the same hormones and neurotransmitters.[19] Psychopathological nature tends to play an etiological role in development of

skin disorders, psoriasis being a key disease in cluster of Psych cutaneous disorder. Seville reported consistent link between major stressful life events and disease manifestation.

Immunological Factors

The skin is the front line of defense against insult and injury and contains many epidermal and immune elements that comprise the skin-associated lymphoid tissue (SALT). The reaction of these components to injury allows an effective cutaneous response to restore homeostasis. Psoriasis is the best-understood and most accessible human disease that is mediated by T cells and dendritic cells. Inflammatory myeloid dendritic cells release IL-23 and IL-12 to activate IL-17- producing T cells, Th1 cells, and Th22 cells to produce abundant psoriatic cytokines IL-17, IFN-γ, TNF, and IL-22. These cytokines mediate effects on keratinocytes to amplify psoriatic inflammation.[20]

Environmental Factors

Environment are important in manifestation of disease indicating several evidence have been implicated in initiation of disease process on exacerbation of pre-existing disease.[21] Factors like mechanical injury, chemical, UV, winter season due to the cold and dry weather and allergies to some food items.

Vikaravighata Bhava[22]

Avikarajananam, reasons for Vikaravighata Bhava are there is no similarities between Dosha Dushya and Nidan with respective to Dravya, Guna, Karma and Prabhav. As Nidan not capable of creating Dhatu Shaithilyata or Khavaigunya, leads to non-manifestation of disease. e.g. If one avoids the Aharaj and Viharaj Kushta Nidana or in other words if one follows diet and life style opposite to Nidana, Doshas Dushyas leads to non-manifestation of disease. Chiren Vikaraja Jananam (delayed manifestation of disease), Nidana as Dushivisha and Chardi Vegdharana in Kushta, there is Anubandha of Nidana Visheshas after long gap due to existence of similarities in Kala and Doshas, similar in genetic factor (Kulaja Nidan). On other hand if Anubandha between Nidan, Dosha, Dushya is very weak the disease occurs in Alpabala with less symptoms, Vyabhichari Hetu of Kushta Roga leads to a mild manifestation of disease.



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Vikaravighata Abhava[22]

Vikarajananam, Infection, immunological, environmental factors of Kushta/psoriasis has similarities in Nidana, Dosha, Dushya in respective of Dravya, Guna, Karma, Prabhava hence easy manifestation of disease occurs. Sheeghra Vikara Jananam, (early manifestation of disease) Anubandha in Nidanadi factors happens very fast as in case of consuming food during Ajeerna Avasta immediate Tridosha Prakopa takes place. Mahati Vikara Jananam (manifestation of severe disease) severity in Dosha Prakopa and four Dushyas leads to pre-existing Dhatu Shaithilyata and there by causes severe vitiation of Dushyas. This leads to manifestation of severity in Kushta (Asadhya/Kashta Sadhya Vyadhi) and may lead to complication. Sarvalinga Yukta Vikara Jananam, extensive Dushya Vaishamyata leads to manifestation of disease with all symptoms mentioned in classics. Hence the study of Vikaravighatakara Bhava Abhava should be useful to understand the pathogenesis of Kushta.

Infection

Most compelling of these is infection with group A streptococci. Streptococcal throat infection precede outbreak of guttate psoriasis which can then lead to chronic plaque psoriasis.[23] Prescription drug use, smoking, chronic inflammation, immunogenic factors. Wide range of injurious local stimuli including physical, electrical, surgical and infective insults have been recognised to elicit psoriatic lesion (Koebner phenomenon). HIV infection an also been associated with psoriasis.[24]

Sansargaja Nidana

Kushta is considered as Sansargaja Vyadhi (communicable or infective disease).[25]

Pathogenesis Psoriasis

It is characterized by hyperproliferation and abnormal keratinocyte. Lymphocyte infiltration mostly of T and various endothelial vascular changes in dermal layers. The epidermis is infiltrated by a large number of activated T cells, which appear to be capable of inducing keratinocyte proliferation. This is supported by histologic examination and immunohistochemical staining of psoriatic plaques revealing large population of T cells with in psoriatic lesions.[26]

Ramped up deregulated inflammatory process ensues with a large production of various cytokines (i.e., tumour necrosis factor- [TnF-α], interferon -gamma, inerleukin-12]. Many of the clinical features of psoriasis are explained by the large production of such mediators. interestingly, elevated levels of TNF-α specifically are found to corelate with lures of psoriasis. Key findings in the affected skin of patients with psoriasis include vascular engorgement due to superficial blood vessel dilation and altered epidermal cell cycle. Epidermal hyperplasia leads to an accelerated cell turnover rate (from 23 days to 3-5 days), leading to improper cell maturation. Cells that normally lose their nuclei, a condition known as parakeratosis. In addition, tp parakeratosis, affected epidermal cells fail to release adequate levels of lipids, which normally cement adhesions of corneocytes. Subsequently, poorly adherent stratum corneum if formed leading to the flaking, scaly presentation of psoriasis lesion, the surface of which often resembles silver scales.[27]

Similarities with oncopathogenesis

As cancer cells may produce abnormal amounts of growth factors (autocrine stimulation) or may stimulate neighbouring cells to produce growth factors (paracrine stimulation). Alteration to the molecules involved in intracellular signalling can also contribute to the continual proliferation of cancer cells. Success of epidermal growth factor receptor (EGFR)- inhibitor in various cancers cells is an example. Mutation and proliferation of epidermal cells less than 23days to 3-5 days forms the abnormal growth of skin cells - there are various types of skin cancer as basal cell carcinoma, squamous cell and melanoma which forms similar pathogenesis in skin and cancer. Tnf- is an inflammatory cytokine produced by macrophages monocytes during acute inflammation. It is responsible for diverse range of signalling events with in cells leading to apoptosis or necrosis.[28]

Samprapti of Kushta

The Doshas which gets vitiated due to the irrespective Hetus spreads throughout the body which in turn vitiates Dhatus in deeper site and manifests disease. Saptha Dravya called Saptha Dushya Sangraha, when disturbed lead to the genesis of Kushta.[29] There are three Doshas - Vata, Pitta and Kapha and four Dushyas - Twak, Mamsa, Rakta


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and Lasika. Due to the Prabhava of Kushta it spreads throughout the body, the dual part played by the Nidana that is simultaneous vitiation of Tridoshas and also Shaithilyata in the Dhatus such as Twak, Rakta, Mamsa and Lasika. Thus, vitiated Tridoshas gain momentum to vitiates Shithila Dhatus and hence the disease Kushta gets manifested.[30]

Nidana Sevana, Doshaja and Karmaja Hetu
↓
Tridosha Prakopa by Avarana of Vata
↓

Twak, Rakta, Mamsa and Ambu Shaithilyata
↓
Vitiated Vata enters in Tiryaka Sira and further vitiation of Doshas occurs
↓
These Doshas gets accumulated at the place of Dhatu Shaithilyata
↓
Dosha and Dushya Samurchhana
↓
Kushtha

Acharya Sushruta described that due to Doshaja and Karmaja Hetus, aggravation of Pitta and Kapha takes place which produce Avarana of Vata which inturn aggravates Vata. Vitiated Vata enters in the Tiryaka Sira with two other vitiated Doshas and their spread leads to further vitiation. After this it reaches to Bahya Rogamarga (Tvak, Rakta, Mamsa, Lasika) and spread throughout the body, producing Mandala at the gathering site of Doshas. If these Doshas are not treated properly. After that they enter into the deeper Dhatus of the body.[31] Thus than Majja Dusti takes place in case of not treated in early stage, creates complication like psoriatic arthritis as Vatarakta (Bheda Avasta).

Discussion

Dermatological disorders are considered as one of the most chronic disorders which is difficult to diagnose and to cure. Genetic, environmental, infections, behavioural dietic factors appear to play a role in pathogenesis of Kushta including psoriasis. Psoriasis involves the hyperproliferation of keratinocytes in epidermis. Findings in the affected skin of patients with psoriasis include vascular engorgement due to superficial blood vessel dilation and altered epidermal cell cycle. Epidermal

hyperplasia leads to an accelerated cell turnover rate (from 23 days to 3-5 days).

Vikaravighatakara Bhava and Vikaravighatakara Abhava plays role in non-manifestation of disease and manifestation of disease respectively. This depends upon the Prativisheshas of Nidana, Dosha, Dushya Visheshas towards Vikara Vighata Bhava and Abhava. A factor which hinders the manifestation of disease in an individual is called Vikara Vighta Bhava. In the absence of Vikara Vighata Bhava manifestation of a disease is possible easily.

Kapha disturbance leads to immunological variations which favours the development of psoriasis. Due to Pitta disturbance, there is a development of hyperproliferation of the keratinocytes in the epidermis. An increase in the epidermal cell turnover rate is because of vitiated Vata. Langerhans cells and myeloid dendritic cells are derived from bone marrow (Majja Dhatu), TNF α (Rakta Dhatu) lymph node (Lasika) which play major role in the pathogenesis of psoriasis.

Conclusion

Present review has mainly focused on different aspects of etiopathogenesis of psoriasis and Kushta. Person’s life with psoriasis may trigger with reoccurrence, unpredictable and severity in one episode to another. Due to the effect of psoriasis in their visibility and ignorance by social public and health care providers, there is an embarrassment physical, mental and socio-economic to the patient. Which further leads to the mental stress and causes aggravates to pre-existing disease. In this way learning the pathology of disease psoriasis is possible with understanding pharmacological intervention in Samprapti Vighatana to improve the mental and physical health. In this way here an attempt is made to understand etiopathogenesis of Kushta and psoriasis with the help of Vikarakighatakara Bhav and Abhav, Amadosha, Kleda, Tridosha, Dusti, Rasa, Rakta, Mamasa, Lasika and Majja Dusti, along with dietetic, environmental, genetic and immunological factors which appears to play role in pathogenesis of Kushta Roga including psoriasis.

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