E-ISSN:2456-3110

Case Report

Plaque Psoriasis

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 8 AUGUST
Publisherwww.maharshicharaka.in

Management of Plaque Psoriasis with Multimodal Treatment of Ayurveda - A Case Report

Gaikwad PP1*, Kaur M2
DOI:10.21760/jaims.9.8.35

1* Pranesh Prakash Gaikwad, Associate Professor, Department of Panchakarma, Dr DY Patil College of Ayurved and Research Centre, Pimpri, Pune, India.

2 Manmeet Kaur, Assistant Professor, Department of Panchakarma, Saraswati Ayurved Hospital and Medical College, Mohali, Punjab, India.

Psoriasis is the immune system problem that causes skin to revitalize at faster rate. It’s the chronic disease that has psychological and social impact on patient’s life. This condition had been narrated many decennium ago but proper aetiology and its cure remain under researched. In Ayurveda this multifaceted etiology disease needs multimodal treatment. The modern treatment provides only temporary relief with too many serious side effects. The treatment embraced here was in accordance with ayurvedic Samprapti. This case report details the successful management of plaque psoriasis in a 32-year-old female patient using a multimodal treatment approach, which incorporated Panchakarma, a traditional Ayurvedic detoxification therapy. The patient presented with erythematous plaques on forehead, neck region, lateral surface of legs and at arms along with itchy and burning skin. Auspitz sign and Koebner phenomenon was positive. Diagnosis made on the basis of Sign and Symptoms. After a thorough evaluation of the patient's constitution and the nature of the disease, a customized Panchakarma protocol was devised involving Virechana (Purgation) followed by Basti (medicated enema) along with Shamana Chikitsa (Internal Medication). The results revealed a remarkable improvement in the patient's psoriasis lesions, with a significant reduction in PASI scores, reduction in scaling, erythema, and in duration. The patient reported a substantial reduction in itching and discomfort. This case report emphasizes the potential of Panchakarma as an adjunctive therapy for plaque psoriasis, highlighting the holistic and personalized approach of Ayurveda in managing chronic skin conditions. Further research and larger-scale studies are warranted to confirm the effectiveness of Panchakarma in the treatment of psoriasis and to observe its long-term benefits and safety profile.

Keywords: Plaque Psoriasis, Virechana, Basti, Shamana Chikitsa, Case Report

Corresponding Author How to Cite this Article To Browse
Pranesh Prakash Gaikwad, Associate Professor, Department of Panchakarma, Dr DY Patil College of Ayurved and Research Centre, Pimpri, Pune, India.
Email: 		Gaikwad PP, Kaur M, Management of Plaque Psoriasis with Multimodal Treatment of Ayurveda - A Case Report. J Ayu Int Med Sci. 2024;9(8):231-238.
Available From
https://jaims.in/jaims/article/view/3458

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-07-13 2024-07-23 2024-08-03 2024-08-13 2024-08-25
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 13.32

© 2024by Gaikwad PP, Kaur 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

Psoriasis is a chronic, inflammatory and immune mediated condition exerts influence on skin. It is the common dermatology disease with prevalence in India is about 0.44-2.8 % and in world affected 2% of population.[1] Plaque psoriasis which is also named as psoriasis vulgaris contribute to 90% of the cases. Red patches along with the white scales on the top are the typical presentation of this type of psoriasis. Scalp, face, trunk, limbs, palms and soles are the sites involved in psoriasis.[2] In psoriasis, main deformity is enhancement of epidermal proliferation due to extreme multiplication of cells at basal layers. The transient time of keratinocytes is reduced and epidermal turnover is reduced from 28-30 days to 5-6 days. The aetiology is unknown and factors involved can be immunopathological, biochemical and genetic. Precipitating factors like trauma, infection, emotions, sunlight or some drugs erupt the disease.[3] There is infiltration of activated T-Cells which elaborate the Cytokines responsible for keratinocyte hyper-proliferation. Agents hampering the T-cell activation or emancipation of pro-inflammatory cytokines will be successful and productive for the treatment of psoriasis.[4] The chronic nature, visibility and recurring pattern have an adverse impact on social and psychological aspects of patient’s daily routine. Diagnosis of this disease is dependent on distribution of skin damage and tissue biopsy. In Ayurveda skin diseases are broadly distributed under a term Kushtha. Eka-Kushtha is the term clarified under Kshudra Kushtha. Its clinical features are virtually similar to that Plaque psoriasis. As an illustration Dry skin or lack of sweating (Asweda), leisons spreading to huge area(Mahavastu),bears the resemblance with scales of fish(Matasya Shakalupma).[5] Due to chronic, relapsing nature and complex pathophysiology of psoriasis the multimodal treatment is adopted i.e. Virechana (purgation), Basti(medicated enema) along with Shamana Chikitsa(internal medication) which makes this case report distinctive.

Patient information

Patient information-A 32-year-old female patient pursuing security guard job diagnosed with plaque psoriasis and was taking allopath treatment from consulting doctor for last 4 years with regular follow ups.

Topical and systematic immunosuppressive drugs were given to patient who resulted in symptomatic relief but if the patient stops taking medicine the symptoms aggravate.

Patient general condition was good. No associated symptoms were found. But due to repetitive pattern caused by unidentified aggravating factors patient consulted for Ayurveda treatment in OPD No. 9 of D.Y. Patil Ayurvedic Hospital, Pimpri, Pune.

Nothing Specific Past illness and No Family History was Present.

Clinical findings

Erythematous plaques on the forehead, neck region, legs and at arms were the presentable symptoms by the patient. The affected skin was having variable shades of red colour and the surface covered with large silvery scales. Burning sensation and itching present all over the affected parts of body. Auspitz sign and Koebner phenomenon were having positive results. Nail bed psoriasis was found to some extent. There was no psoriatic arthritis.

Diagnostic assessment

The Ayurveda has unique way of examining of patient and making diagnosis of disease.

Table 1: Eight-fold assessment by Ayurveda system

SNAyurveda investigative parametersFindings
1.Examination of Pulse70/min (Pitta Pradhana Vaata Anubandi)
2.Examination of StoolRegular once or twice per day
3.Examination of UrineRegular, 4-5 times/day
4.Examination of TongueSlightly coated
5.Examination of Sound / VoiceNormal
6.Examination of Touch / SkinDry, Scaly and Erythematous
7.Examination of EyesNo Significant abnormality
8.Examination of BuiltGood, No abnormality (64Kg weight)

Systemic Examination

No abnormality detected in Central Nervous System, Respiratory system and Cardiovascular system but the patient was uneasy due to itching and burning sensation over psoriatic lesions.

Nidana (Cause)

Ahaaraj (Dietary Causes) - Virudha Ahaar Sevana (simultaneous use of milk and salty snacks)


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Raktadushtikar Ahaar Sevana (excessive use of salty food, sour food like pickles and curd.

Vihaaraj (lifestyle causes): due to job there is excessive exposure to sunlight.

Samprapti (Pathophysiology according to Ayurveda perspective)

Causative factors Vaatadi Dosha vitiation

↓

Circulation of vitiated Dosha in all body channels

↓

Affect Twaka, Mamsa, Rakta, Lasika

↓

Localization of vitiated Doshas and of skin Dushyas in Twaka

↓

Psoriasis discolouration and scaling

Table 2: Samprapti Ghataka (Pathophyisiology Contents)

DoshaVaata, Pitta, Kapha and Rakta
DushyaRasa, Rakta and Mamnsa dhatu
Agni (Digestive fire)Mandagni (Low) (Jatharagni and Dhatvaagni)
Strotas (Channels)Rasavaha, Raktvaha and Mamsvaha Strotas
Adhisthana (Area of Localization)Twaka Vikaara
RogamargaBahya
SwabhavaChirkari (Chronic)
SadhyaasadhyataKricchasadhya (difficulty to treat)

Poorva Roopa (Prodromal stage):Abhyaantra Daha (feeling of warmth), Kandu (Itching), Mandaagni (low digestive fire).

Roopa (Symptoms): Jwara (fever), Trishna (thirst), Daha (burning sensation), Kandu (Itching), Twakvaivarnya (discolouration).

Based on clinical presentation, Positive Auspitz sign and Koebner phenomenon confirm diagnosis of plaque psoriasis. Due to financial condition of Patient Biopsy cannot be afforded by patient.

Therapeutic procedures

The Shodhana therapy i.e., Virechana (Purgation) along with Shamana (Balance vitiated Dosha with medical treatment follow by Pathya (Do’s & Don’ts). Before Shodhana, Deepana Pachana was done.

Table 3: Deepana Pachana

SNMedicine prescribedDoseAnupanaTimingsDays
1.Sutshekhar Ras500mgLukewarm waterT.D.S before meal3 days
2.Guduchi Ghana Vati500mg
3.Sukshama Triphala60mg
4.Anulomak Vati500mgAt night

Then Abhyantra Snehpana (Internal Oleation) with Panchatikta Ghrita was started for 6 days in increasing order from 30 ml to 180ml, each day 30 ml is increased.

Followed by Mridu Bahya Snehana (external oleation) with Nimba Taila and Swedana with Dashmoola Kwatha for 2 days (These are called Vishram Diwas).

Then Virechana Karma was performed

Virechana Dravya:Trivrut Leham: 30mg

Virechanaopaga Dravyas: Triphala Kwatha:100ml

Manuka Phant:100ml

Total 26 Vega (counts) were there

Followed by 7 days Sansarjana Karma (Dietary Regimen)

Timeline

After Virechana and Sansarjana Krama all the internal medications were continued for 3 months with regular follow ups and some changes in medication

List of internal and external medications with dose

These medicines were given for 3 months.

Table 4: Internal Medication

SNMedicine prescribedDoseAnupanaTimingsDays
1.Sutshekhar Rasa500 mgLukewarm waterT.D.S before meal1 week
2.Mahasudarshana Ghana Vati250 mgLukewarm water
3.Guduchi Ghana Vati250 mglukewarm water
4.Raktashodhaka Vati250 mglukewarm water
5.Anulomaka Vati500 mgAt night 2 hours after night meal
6.Nimba TailaLocal ApplicationTwice a day

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After 1 week of medicine patient came to O.P.D with complaints of constipation and patient has also history of piles. So, some changes in medicines were made.

Table 5: Internal medication

SNMedicine prescribedDoseAnupanaTimingsDays
1.Sutshekhar Rasa500 mgLukewarm waterT.D.S before meal30 days
2.Guduchi Ghana Vati250 mg
3.Suran Vatak250 mg
4.Arshakuthar Rasa250 mg
5.Raktashodhaka Vati250 mgT.D.S after meal
6.Aarogyavardhini Vati250 mg
7.Panchtiktak Ghrita5mlB.D before meal
8.Anulomaka Vati500 mgAt night 2 hours after night meal

After approx. 1 month of follow up Sukshama Triphala 250 mg was added thrice a day after meal with lukewarm water for another 30 days

In Varsha Ritu (Rainy season) Yoga Basti (Medicated Enema Therapy) was advised to patient for 8 days with the order of A-N-A-N-A-N-A-A.

Table 6: Yoga Basti Krama

Anuvasan BastiKaranja Taila (30ml) + Nimba Taila (80ml)
Niruha BastiKwath prepared with Vidanga, Dashamool, Manjishtha, Sariva each 10gm - 160 ml
Makshika - 80 ml
Lavana - 5 gm
Panchatiktak Ghrita - 120 ml
Kalka (Dravya same as used in Kwatha each 10gm) - 40 gm

The medicines followed during and after 3 months of Yoga Basti.

Table 7: Abhyantar Chikitsa (internally given medicines)

SNMedicine prescribedDoseAnupanaTimingsDays
1.Sutshekhar Rasa500mgLukewarm waterT.D.S before meal3 months
2.Guduchi Ghana Vati250mgLukewarm waterT.D.S before meal
3.Raktashodhak Vati250mglukewarm waterT.D.S after meal
4.Aarogyavardhni Vati500mglukewarm waterT.D.S after meal

There was 80% decrease in the psoriatic lesions. No adverse events witnessed during treatment.

Psoriasis Area and Severity Index (PASI)

Table 8: PASI Score Calculation

Before TreatmentAfter 3 monthsAfter 8 months
“0.1 (Eh+Ih+Dh) Ah+ 0.2(Eu+Iu+Du)Au + 0.3(Et+It+Dt)At + 0.4(El+IL+Dl)Al”
0.1(2+2+3)3 + 0.2(3+2+1)4 + 0.3(3+2+2)3 + 0.4(3+3+4)5
2.1+4.8+6.3+20.0 = 33.2		“0.1(Eh+Ih+Dh)Ah + 0.2(Eu+Iu+Du)Au + 0.3(Et+It+Dt)At + 0.4(El+IL+Dl)Al”
0.1(1+1+2)3 + 0.2(2+1+1)4 + 0.3(2+1+2)3 + 0.4(2+2+3)5
1.2+3.2+4.5+14.0 = 22.9		“0.1(Eh+Ih+Dh)Ah + 0.2(Eu+Iu+Du)Au + 0.3(Et+It+Dt)At + 0.4(El+IL+Dl)Al”
0.1(0+0+1)2+ 0.2(0+0+0)1 + 0.3(1+0+1)2 + 0.4(1+1+2)3
0.2+0+1.2+4.8 = 6.2

Head (h), Upper limb (u), Trunk (t) and lower limb (l) are the sites of affected region and the 3 parameters used are Erythema, Induration and Desquamation. Each parameter is based on gradation from 0-4 where 0 stands for nill, 1 is mild, 2 – moderate, 3 - severe and 4 - very severe. Area of involvement is graded from 0-6 where 1 is marked if less than 10% area involved, 2 for 10-29%, 3 for 30-49%, 4 for 50-69%, 5 for 70-89% and 6 for more than 90% area involved. Photographs of affected area before and after 8 months of treatment have been taken. And after active treatment patient was still advised for strict diet and no reoccurrence is observed.

Prior to treatment
jaims_3458_01.JPG


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After 3 months of treatment
jaims_3458_02.JPG

After 8 months of Treatment
jaims_3458_03.JPG

Table 9: Summary of whole treatment

DurationTreatment
15/03/2021 - 17/03/2021Deepana Pachana
18/03/2021 - 23/03/2021Ghritpana
24/03/2021 - 25/03/2021Vishram Diwas
26/03/2021Virechana performed
26/03/2021 - 01/04/2021Sansarjana Krama
02/04/2021 - 14/07/2021Internal Medication with modifications at regular follow ups
15/07/2021 - 22/07/2021Yoga Basti
1/08/2021Follow up with changes in ongoing internal medication

Discussion

The fiery outpouring, keratinocytes, and cytokines are central participants in the pathophysiology of psoriasis. Portrayed by raised red skin patches encompassed by brilliant white scales.[6] Vaata Pitta Kapha were Doshas in this case, Rasadhatu, Raktadhatu, and Mamsadhatu were Dushyas. With the flow of vitiated Doshas and their Sthansamshrya (site of neurotic changes at Twaka with the clinical show of Vyadihilakshna), Dosha Dushya Samurrachana (obsessive advancement) was occurred.[7] A vitiated Vaata produces scaling, dryness, and distress. Redness and aggravation are the consequences of vitiated Pitta, while rashes from vitiated Kapha cause tingling, itching, and thickening of the skin. As per Ayurvedic texts, psoriasis is a draining condition with vitiated Doshas.[8]

In attenuation of Kevala Pitta, Pitta associated with Kapha and in Pittasthangata Kapha, treatment procedure to be followed is Virechana. However, before Virechana Deepana Pachana is done because it brings the Doshas from Sama state to Nirama state.[9] For Virechana the drug used is Trivruta Aveleha which not only removes vitiated Pitta but also have effective modality in morbid Kapha and Rakta. Daha and Kandu is reduced with the elimination of Pitta and morbid Kapha. Rukshata and Shyamvarnta is reduced due to Vaatanulomaka properties.[10] Virechana Upgaga Dravyas like Triphala Kwatha and Manuka Phanta helps to ease the process of Virechana.


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Anuvasana Basti of Karanja Taila has Swedaghna, Kandoghna, Kushthaghna, Dahprashmana, and Sthirikarana properties. Basti of Karanja Taila delivered positive results for psoriasis victims. Karanja Taila have been displayed to have hostile to oxidant, mitigating, immuno-stimulatory, and immuno-modulatory properties.[11] Niruha Basti was prepared with Vidanga, Dashamoola, Manjishtha, Sariva as the main ingredients having Vaataanulomaka, Raktaprasadaka and Pittaghana properties and through its systemic action Basti is capable of removing the Doshas from whole body.

The pathological changes were corrected by following medications such as Sutshekhar Rasa, Guduchi Ghana Vati, Raktashodhak Vati, Aarogyavardhni Vati. Mahasudarshana Ghana Vati, Panchatikta Ghrita, Anulomak Vati.

Sutshekhar Rasa assists with assuaging the Pitta and Vaata, keeping away from the reoccurrence of this condition. Raktashodhak Vati is a perfect invention of nine spices used to fortify the safe framework and decontaminate blood. It assists with all skin conditions since it cleanses the blood and liver of all poisons. Guduchi is Tridoshshamak and Kushthagana, further develops assimilation, evades arrangement of Aama, and is successful in different skin sicknesses.[12] Arogyavardhni Vati is said by Rasratansamuchya, Bhaisajyaratnavali, and Bharatbhaisajyaratnakar to have the pharmacological movement of Kushthanashaka.[13] Mahasudarshan Ghan Vati with its strong antimicrobial, antibacterial, and clean properties, this astonishing tablet is fundamental for forestalling many irresistible illnesses.[14] It forestalls various skin sensitivities as well as bringing down the gamble of a few viral and contagious sicknesses. Nimba Taila has Kushtaghana, Vranahara and Krimighana Properties.[15] Surana Vataka and Arshkuthara Rasa improves digestion and helpful in haemorrhoids and constipation. Panchatita Ghrita has Snigdha and Pitta balancing properties which helps to reduce irritation, inflammation, itching and dryness.

To measure extent and severity of psoriasis PASI (Psoriasis Area and Severity Index) Score is one of the tools used. Their ranges vary from 0-72. Assessment was taken prior to treatment, following 3 months of treatment and after 8 months of treatment. The score was reduced from 33.3 to 6.2 within 8 months of treatment.

Conclusion

Treatment protocol adopted in present case was according to Ayurveda pathophysiology. According to the predominance of Doshas Virechana was planned which removes the morbid Doshas from body, Basti removes the toxins as well as calm down the vitiated Doshas at their respective places and internal medication is a palliative approach further normalizes the Doshas. No reoccurrence was observed after the end of active treatment but still strict diet and medication was advised to the patient. Complete elimination of this disease is nearly impossible all we can do is to improve the quality of life through recurrent interventions, preventing the symptoms from annoying patient’s daily routine. Altogether, multimodal treatment of Ayurveda led to prompt recovery from chronic case of psoriasis.

Limitation and Further Scope

This disease requires repeated Shodhana with the frequent intervals which provides the further scope to the researchers to see the periodic use of panchakarma in psoriasis.

Informed consent

Consent was attained for publishing photographs.

References

1. DM T, M M. Research on psoriasis in India: Where do we stand? Indian J Med Res. 2017;146(2):147–9.
2. Griffiths CEM, Armstrong AW, Gudjonsson JE, Barker JNWN. Psoriasis. Lancet. 2021;397:1301–15.
3. Nille GC, Chaudhary AK. Potential implications of Ayurveda in Psoriasis : A clinical case study. J Ayurveda Integr Med [Internet]. 2021;12:172–7. Available from: https://doi.org/10.1016/j.jaim.2020.11.009
4. Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL. Harrison’s principles of internal medicine. 17th ed. Newyork: McGraw Hill Education; 2008. 316 p.
5. Pandit Kashinath Shastri (reprint edition), Charak chikitsa Sthana, Kustha chikitsa adhyaya-chapter 7, Varanasi; Chaukhambha prakashana, 2006; 203.
6. Lowes MA, Suarez-Farinas M, Krueger JG. Immunology of Psoriasis. Annu Rev Immunol. 2014;32:227–55.


J Ayu Int Med Sci 2024;9(8)236
Pranesh PG et al. Plaque Psoriasis with Multimodal Treatment of Ayurveda

7. Telles S, Pathak S, Kumar A, Mishra P, Balkrishna A. Ayurvedic Doshas as Predictors of Sleep Quality. Med Sci Monit. 2015;21:1421–7.
8. https://www.theayurveda.org/ayurveda/psoriasis-symptoms-cause-types..Date-20/11/2023.Time 16:00 IST.
9. Pandey RK, Bhatt NN, Singhala TM, Shukla VD. A comparative study of Vamana and Virechana Karma in the management of Sthula Pramehi w.s.r. to Type ‑ 2 diabetes. Ayu. 2011;32(4):536–9.
10. Doddagoudar S, Patil P. A Clinical study on the Efficacy of Virechana karma followed by Pathyadi lepa in the management of Kitibha kushta w.s.r to Psoriasis. RGUHS J AYUSH Sci. 2018;5(2):2–6.
11. Kumar KK, Chacko J. Thuvaraka rasayana regimen in Psoriasis vulgaris - A case report. J Ayurveda Integr Med [Internet]. 2019;10:41–4. Available from: https://doi.org/10.1016/j.jaim.2018.04.003
12. Kadam D, Suryakar AN, Ankush R, Kadam C, Deshpande K. Role of Oxidative Stress in Various Stages of Psoriasis. Indian J Clin Biochem. 2010;25(4):388–9
13. Upadhyay AK, Kumar K, Kumar A, Mishra HS. Tinospora cordifolia (Willd.) f. and Thoms. (Guduchi) – validation of the Ayurvedic pharmacology through experimental and clinical studies. Int J Ayurveda Res. 2010;1(2):112–21.
14. Kumar G, Srivastava A, Sharma SK, Gupta YK. Safety evaluation of an Ayurvedic medicine, Arogyavardhini vati on brain , liver and kidney in rats. J Ethnopharmacol. 2012;140(1):151–60.
15. Karki A, Yalagond MS, Illal V. A Comparative Study on the effect of Padabhyanga with Tila Taila and Nimba Taila in management of Vipadika w. s. r. to Padasputana. J Ayurveda Integr Med Sci. 2018;3(4):18–23.


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