E-ISSN:2456-3110

Case Report

Plaque Psoriasis

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 12 December
Publisherwww.maharshicharaka.in

Ayurvedic management of Plaque Psoriasis - A Case Study

Paul A1, Neethu Ks2*
DOI:10.21760/jaims.8.12.41

1 Ajay Paul, Associate Professor, Department of Kayachikitsa, Ayurveda College Hospital, Coimbatore, Tamil Nadu, India.

2* Neethu Ks, Associate Professor, Department of Kayachikitsa, Ayurveda College Hospital, Coimbatore, Tamil Nadu, India.

Psoriasis is a chronic inflammatory disease affecting mainly in skin and joint. In Ayurveda, under the umbrella of Kushtha all skin diseases are described. In management of Psoriasis Ayurvedic system of medicine is giving good results. The main line of treatment of skin diseases in Ayurveda is repeated Samshodhana (purificatory therapies) along with Samshamana (palliative therapies). Three assessments were done before and after treatment on scoring of Dermatology Life Quality Index (DLQI), Psoriasis Disability Index (PDI) and PASI score. Score of the patient was 83% before treatment and 16% after treatment and 10% after follow up on Dermatology Life Quality Index (DLQI), 86% before treatment and 65% after treatment and 41% after follow up on Psoriasis Disability Index (PDI) and 35.5% before treatment, 10.2% after treatment and 8% after follow up in PASI (Psoriasis Area and Severity Index). This case study wants to substantiate the effectiveness of Ayurvedic treatment in the management of Plaque psoriasis.

Keywords: Skin disease, Plaque Psoriasis, Psoriasis, Kushta, Sidhma, Eka kushta, Dermatology life quality index, Psoriasis Disability Index, Psoriasis Area, Severity Index

Corresponding Author How to Cite this Article To Browse
Neethu Ks, Associate Professor, Department of Kayachikitsa, Ayurveda College Hospital, Coimbatore, Tamil Nadu, India.
Email: 		Paul A, Neethu Ks, Ayurvedic management of Plaque Psoriasis - A Case Study. J Ayu Int Med Sci. 2023;8(12):269-277.
Available From
https://jaims.in/jaims/article/view/2971

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-10-12 2023-10-22 2023-11-02 2023-11-12 2023-11-24
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 23.96

© 2023by Paul A, Neethu Ksand 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

Psoriasis is a common dermatologic disease, affecting up to 1% of the World’s population,[1] both males and females suffering equally.[2] The word Psoriasis is derived from Greek word ‘Psora’ means ‘itch’ and ‘sis’ meaning ‘acting condition’. It has a bimodal age of onset (16 to 22 and 57 to 60 years).[3]

Psoriasis is a chronic, multisystem inflammatory disease involvement of skin and joint in predominant. Psoriasis has an emotional and psychosocial effect on patients more than physical dimensions of disease affecting social functioning and interpersonal relationships.[4] Pathogenesis is multifactorial, involving genetic associations and dysregulated inflammation.[5] Psoriasis is a systemic inflammatory disease, it is associated with multiple co morbidities, including cardiovascular disease and malignancy. Appropriate treatment is initiated, depending on the severity of disease. Diagnosis of psoriasis is primarily clinical and a skin biopsy is rarely required. There are different clinical types of psoriasis, the most common of which is chronic plaque psoriasis, affecting 80% to 90% of patients with psoriasis. Classic plaque psoriasis is well-demarcated, symmetric, and erythematous plaques with overlying silvery scale. Plaques are typically located on the scalp, trunk, buttocks, and extremities but can occur anywhere in the body. Patients might demonstrate nail involvement, which can see without concomitant plaques. Active lesions might be painful or itchy. Psoriasis can also present as an isomorphic response, where new lesions develop on previously normal skin that has sustained trauma or injury (Koebner’s phenomenon). For mild to moderate disease, first-line treatment in conventional medicine involves topical therapies including vitamin D3 analogues, corticosteroids, and combination products.[6]

There is no satisfactory treatment available for Psoriasis in conventional medical system. However, Ayurvedic system of medicine is giving good results in management of Psoriasis. In Ayurveda all skin diseases are described under the sunshade of Kushtha. There are several types of Psoriasis which can be related to certain conditions mentioned in Samhitas. Since Vedic period description of Kushtha is present, Ekakushtha is described in Garuda Purana[7] and in almost all Ayurvedic

classics after that period like Brihattrayi, Laghutrayi and all texts afterwards. Ekakushtha is mentioned in all Ayurvedic classics under Kshudrakushtha and has predominance of Vata and Kapha Dosha.[8] Another type of Kushta Sidhma Kushta, characterized by thin white/ coppery lesions with predominant scaling is also mentioned in Ayurveda.[12] These etiological factors lead to vitiation of Tridosha especially Vata and Kapha.

The causative factor of Ekakushtha and Sidhma is same as Kushtha. Dietary factors like Viruddha Aahara (incompatible foods), excessive consumption of Drava, Snigdha, Guru Aahar (excess use of foods which are liquid, unctuous and difficult to digest), Vega Dharana (suppression of urges) especially vomiting are the major aetiologies as per Ayurveda. As a causative factor for the disease indulgence in sinful act is also described.[9] Acharya Charaka has mentioned the symptoms of Ekakushtha as Mahavastu (big), Aswedanam (without sweating), and Matsyashakalopamam (like scales of fish)[10] and Acharya Sushruta described its symptoms as Krishna Aruna Varnata (blackish red lesions).[11] Three Doshas, Vata, Pitta and Kapha through Tiryakvahini Siras proceed to Bahya Rogamarga i.e., Twacha, Rakta, Mamsa and Lasika and cause disease.[13] Repeated Samshodhana (purificatory therapies) along with Samshamana (palliative therapies) is the main line of treatment of skin diseases in Ayurveda.[14] Shodhana removes Vruddha (vitiated) Doshas from the body. Shamana stabilizes Doshas in our body. So, both Antaparimarjana and Bahirparimarjana Chikitsa was done.

This case study wants to substantiate the effectiveness of Ayurvedic treatment in the management of Plaque psoriasis. Three assessments were taken before and after treatment on scoring of Dermatology Life Quality Index (DLQI), Psoriasis Disability Index (PDI) and PASI score. Score of the patient was 83% before treatment and 16% after treatment and 10% after follow up on Dermatology Life Quality Index (DLQI), 86% before treatment and 65% after treatment and 41% after follow up on Psoriasis Disability Index (PDI) and 35.5% before treatment, 10.2% after treatment and 8% after follow up in PASI. Written informed consent was obtained from the patient for the publication of this case report.

A 34-year-old male patient was symptomless before


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8 years, he had gradual developing symptoms such as redness of skin, silvery scaly skin, burning sensation along with severe itching, and no sweating over both forelimbs. So, he took allopathic treatment for one year but he got only symptomatic temporary relief, there was decrease in itching only. That is why before 6 months, he approached our hospital for management. Patient took treatment, although he got mild relief in first stage, symptoms aggravated later. In December, the condition was worsened due to cold climate.

Past History

Family history: Father (K/C/O eczematic lesion)

Personal history:

  • Diet: Non-vegetarian twice a week
  • Addiction: Alcohol consumption occasionally
  • Sleep: Disturbed

Diagnosis and assessment

On the basis of clinical history and examination the condition was diagnosed. Signs and symptoms like well-circumscribed erythematos papules/plaques covered with dry, brittle, silvery grayish, white micaceous scales, Auspitz sign, Koebner phenomenon, Candle grease sign, etc. were present.

Criterion of assessment was based on the scoring of Dermatology life quality index (DLQI), Psoriasis Disability Index (PDI) and PASI score.

1. Dermatology life quality index (DLQI)

2. Psoriasis disability index (PDI)

3. PASI score

The DLQI is a questionnaire relating to the previous activities and feelings. Work, school, leisure, daily activities as well as the symptoms and feelings are measured as well as personal relationships and the impact of treatment. It is calculated by summing the score of each question, resulting in a maximum of 30 and a minimum of 0. The higher the score, the more the Quality of Life is impaired. The DLQI can also be expressed as a percentage of the maximum possible score of 30.

The psoriasis disability index

This is a questionnaire addressing 15 aspects including daily activities, personal relationships,

vacation, work as well as the effects of actual treatment. This has been used in a number of clinical studies.

Table 1: Dermatology life quality index - DLQI

Before treatmentAfter treatmentAfter follow up
83%16%10 %

Figure 1: Dermatology life quality index - DLQI

Table 2: The psoriasis disability index-PDI

Before treatmentAfter treatmentAfter follow up
86 %65 %41%

Figure 2: The psoriasis disability index-PDI

PASI Score: The current gold standard for assessment of extensive Psoriasis has been the Psoriasis area severity index (PASI). PASI combines the assessment of the severity of lesions and the area affected into a single score in the range 0 (no disease) to 72 (maximal disease). The PASI is a measure of the average redness, thickness and scaling of the lesions (each graded on a 0-4 scale), weighted by the area of involvement.

Table 3: Psoriasis area severity index (PASI)

Before treatmentHead and neckArmsTrunkLegs
Skin area involved score<10%30-49%70-80%30-49%
Redness2332
Thickening1444
Scaling1444
PASI score: 35.5

Table 4: Psoriasis area severity index (PASI)

After treatmentHead and neckArmsTrunkLegs
Skin area involved score0%10-29%30-49%10-29%
Redness0222
Thickening0121
Scaling0121
PASI score: 10.2

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Table 5: Psoriasis area severity index (PASI)

During follow upHead and neckArmsTrunkLegs
Skin area involved score0%10-29%30-49%10-29%
Redness0122
Thickening0111
Scaling0111
PASI score: 8.0

Figure 3: PASI score before, after and during follow-up.

Table 6

DurationMedicineDoseFrequency
12/10/2022 - 06/10/2022
19/11/2022 - 01/12/2022 (except days of Snehapana, Vaman, Virechan)		Patolamuladhi Kashayam60mlTwo times a day before food
Dushivishari Gulika1Two times a day with Kwatha
24.2.2019 - 1.3.2019Madhusnuhi Rasayanam1 table spoonTwice a day after food
2.3.2019 - 30.3.2019Aragwadhamahatiktaka Ghrita1 tablespoonAt bed time

Table 7

DurationTreatment
06/11/2022 - 08/11/2022Rookshana with Vaiswanara Choorna - 2 teaspoon with hot water twice a day before food
09/11/2022 - 15/11/2022Snehapana with Aragwadha Mahatiktaka Ghrita (internal administration of medicated ghee in gradually increasing dose upto 210 ml)
16/11/2022 - 17/11/2022Nimbapatra Potalasweda (a type of fomentation) and Abhyanga (oil massage) with Dantapala Kera and Jeevantyadi Yamakam
17/11/2022Vamana (Emesis) with Vacha, Yasthi, Madana Pippali, Nimba Swarasa and Madhu
17/11/2022 - 21/11/2022Samsarjanakrama (for increasing the digestive power after Vamana therapy)
22/11/2022 - 23/11/2022Abhyanga (oil massage) with Dantapala Kera and Jeevantyadi Yamakam and bathing with Kashaya Dhara with Aragwadhadi Kashayam
24/11/2022 - 28/11/2022Abhyanga (oil massage) with Dantapala Kera and Jeevantyadi Yamakam Takradhara processed with Aragwadhadi Gana
29/11/2022Virechana (purgation) with Avipathi Churnam 30 gm with milk
29/11/2022 - 01/12/2022Samsarjanakrama (for increasing the digestive power after Virechana therapy)

Table 8

DurationMedicineDoseFrequency
02/12/2022 - 29/12/2022Manjistadi Kashayam + Sonithamritham Kashayam60mlTwo times a day before food
Dushivishari Gulika1Two times a day with Kwatha
Tab. Gandaka Rasyanam1Two times a day after food
02/12/2022 - 29/12/2022Madhusnuhi Rasayanam1 tablespoonTwo times a day after food
02/12/2022 - 29/12/2022Aragwadhamahatiktaka Ghrita1 tablespoonAt bed time
26/12/2022Tamra Bhasama150 mgAfter food

Discussion

Psoriasis is a chronic, multisystem involving inflammatory disease with predominantly skin and joint involvement. In Ayurveda, all skin diseases are described under the umbrella of Kushtha. Symptoms of Sidhma, characterized by thin white/coppery lesions with mainly scaling are the classical features of Plaque psoriasis. Another type of Kushta called Ekakushta, a type of Kushta with symptoms like Mahavastu, Aswedanam, Matsyashakalopamam, Krishna- Aruna Varnata can also be corelated to plaque psoriasis. Frequent Samshodhana along with Samshamana is the main line of treatment. Shodhana is very important in the management of Kushta because doing external applications without cleansing the body internally by Shodhana procedures will lead to the aggravation of skin disease.

As preparatory procedures, Snehapana with Aragwadha Mahatiktaka Ghrita (indicated in all types of Kushta) for 7 days and Nimbadi Patrapotala Sweda (found effective in palque psoriasis) for 3 days were done. Vamana was done with Vacha, Yasthi, Madana Pippali, Nimba Pallava Swarasa and Madhu (As per Visarpa Chikitsa to be followed in Kusta Chikitsa) then Virechana was done with Avipathi Churna along with milk. Vamana is also found highly effective in the management of skin diseases. Virechana is effective in Kustha as Kushta Tridosha Roga to mitigate Pitta Pradhana Tridosha.

After Samsarjanakrama, it was followed by Abhyanga (oil massage) with Dantapala Kera and Jeevantyadi Yamakam and Kashaya Dhara along with Aragwadhadi Kashaym, followed by Takradhara processed with Aragwadhadi Kashayam. Takradhara is a Ayurvedic traditional procedure useful in treating psychosomatic disorders, psoriasis, hypertension, lack of sleep etc. Takra contains all the five Rasa (tastes) except Lavana (salty). It has Usna Virya


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(hot potency) and Amla Vipaka (sour transformation of taste) and also has Vata Kapha Nashaka (alleviates Vata and Kapha Dosha) properties. Takra processed with Aragwadhadi Kashayam is enhancing to mitigate skin disease and psycho somatic disease.

Before Treatment

As internal medicines, Patolamuladhi Kashayam, Dushivishari Gulika, Aragwadhamahatiktaka Ghrita, Madhusnuhi Rasayanam, Tab. Gandaka Rasyanam, Tamra Bhasma were prescribed. All medicines are Kushtahara (alleviates skin diseases), Raktadushtihara (cleansing Rakta dhatu), Srotovishodhana (cleansing channels of body), Vishahara in nature. Madhusnuhi Rasayanam is Kushtahara (alleviates skin diseases). The patient was discharged after 1.5 months of treatment. Manjistadi Kashayam + Sonithamritham Kashayam, Tab. Gandaka Rasyanam, Dushivishari Tablet, Madhusnuhi Rasayanam, Dantapala Kera and Jeevantyadi Yamakam + Nalpmaradhi Thailam were given as discharge medicines, which are Raktadushtihara, Pittadoshahara, Anulomana, Vishahara in nature. During follow up after 2 months of treatment, patient reported good relief in all complaints.

Three assessments were taken before and after treatment on scoring of Dermatology Life Quality Index (DLQI), Psoriasis Disability Index (PDI) and PASI score. Score of the patient was 63.3% before treatment and 13.3% after treatment and 3.3% after follow up on Dermatology life quality index (DLQI), 44.4% before treatment and 15.5%after treatment and 5.3% after follow up on Psoriasis Disability Index (PDI) and 24.5%


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before treatment, 5.1% after treatment and 1.2% after follow up in PASI. The present case report substantiates effectiveness of classical Ayurvedic management in Plaque Psoriasis. For prevention of further exacerbation and to decrease the frequency of relapse, periodic panchakarma interventions are advised. It also prevents the progress of the condition into complications like Psoriatic arthritis.

After Treatment

After Follow-up


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Vamana Karma - Testing Pitta Antham with Sulphur powder

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6. Kim WB, Jerome D, Yeung J. Diagnosis and management of psoriasis. Can Fam Physician. 2017 Apr; 63(4): 278–285.


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