E-ISSN:2456-3110

Case Report

Palmoplantar Psoriasis

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 9 SEPTEMBER
Publisherwww.maharshicharaka.in

Therapeutic interventions and clinical efficacy in Ayurvedic management of Vipadika (Palmoplantar Psoriasis): A Case Report

Topiwala S1*, Taviad K2, Kalsariya B3
DOI:10.21760/jaims.9.9.44

1* Sahil Topiwala, Post Graduate Scholar, Department of Rasashastra and Bhaishajya Kalpana, Government Ayurved College and Hospital, Vadodara, Gujarat, India.

2 Krushnkumar Taviad, Assistant Professor, Department of Rasashastra and Bhaishajya Kalpana, Government Ayurved College and Hospital, Vadodara, Gujarat, India.

3 Bharat Kalsariya, Professor and Principal, Department of Rasashastra and Bhaishajya Kalpana, Government Ayurved College and Hospital, Vadodara, Gujarat, India.

Vipadika, a skin disorder mentioned in Ayurvedic literature as Kshudra Kustha attributed to Vata and Kapha Dosha imbalance, is analogous to palmoplantar psoriasis in contemporary science. It is a non-infectious chronic inflammatory disease of the skin bound to the palm and sole. It is characterized by pain, itching, and fissures in both soles. Contemporary treatment options often lead to temporary relief with frequent recurrence, leading patients to seek alternative therapies. The present case report aims to assess the therapeutic efficacy of Ayurvedic management in treating Vipadika. A 58-year-old female presented with pruritus, fissures in both sole and severe pain with oozing of bleeding from fissures across both soles; diagnosed as Vipadika. The treatment approach exclusively involved Shamana Chikitsa, including the oral administration of Panchatikta Ghrita, Gandhaka Rasayana, and Avipattikara Churna. Topical care was provided by washing the affected area with Panchavalkala Kwatha mixed with Shuddha Tankana for debridement. After washing, the patient was advised to use a foot scrubber for scrubbing the dead skin around the fissures followed by Jatyadi Malam for topical use. The patient's response was assessed over ten weeks, with follow-up for four weeks to determine using symptom improvement, patient-reported outcomes, and Auspitz sign. This case demonstrates the potential of Ayurvedic therapies for the effective management of Vipadika, suggesting a viable alternative to conventional treatment approaches.

Keywords: Ayurved, Kshudra Kustha, Skin Disease, Shamana Chikitsa

Corresponding Author How to Cite this Article To Browse
Sahil Topiwala, Post Graduate Scholar, Department of Rasashastra and Bhaishajya Kalpana, Government Ayurved College and Hospital, Vadodara, Gujarat, India.
Email:
Topiwala S, Taviad K, Kalsariya B, Therapeutic interventions and clinical efficacy in Ayurvedic management of Vipadika (Palmoplantar Psoriasis): A Case Report. J Ayu Int Med Sci. 2024;9(9):274-281.
Available From
https://jaims.in/jaims/article/view/3629

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-08-14 2024-08-24 2024-09-04 2024-09-14 2024-09-22
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 12.32

© 2024by Topiwala S, Taviad K, Kalsariya Band 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].

Introduction

In Ayurvedic literature, the term Kustha is used as a broad classification encompassing a variety of dermatological conditions. These conditions are further classified into two categories: Maha Kustha (major skin diseases) and Kshudra Kustha (minor skin diseases), comprising seven and eleven types, respectively.[1] According to Acharya Charaka, all forms of Kustha arise from an imbalance of the Tridosha.[2] This imbalance affects the Twak, Rakta, Mamsa, and Ambu, leading to various dermatological manifestations.[3]

Vipadika, a dermatological condition mentioned in Ayurvedic literature as Kshudra Kustha attributed to Vata and Kapha Dosha imbalance leads to vitiation of Rakta Dhatu,[4] characterized by Panipada Sphutna (fissures in palm and sole) associated with Teevra Vedana (excessive pain).[5] Acharya Vagbhatta added the symptoms like Manda Kandu (mild itching), and Saraga Pidika (red patches) in it.[6] In contrast, Acharya Sushruta highlights Kandu (itching), Daha (burning sensation), and Vedana (pain), particularly affecting the Pada (soles), as the main characteristics of the condition.[7] Vipadika, symptomatically can be correlated with the palmoplantar psoriasis.

Palmoplantar psoriasis is a chronic, immune-mediated, inflammatory, and proliferative non-communicable skin disorder, primarily affecting the palms and soles. The global prevalence of psoriasis is estimated to range between 2% and 3%, while in India, it varies from 0.44% to 2.88%. The condition is influenced by both genetic and environmental factors.

The most commonly associated genetic factor is the Human Leukocyte Antigen (HLA) Cw6. Environmental triggers include smoking, exposure to irritants, and repetitive or manual trauma. Clinically, palmoplantar psoriasis is characterized by thick hyperkeratotic plaques, sterile pustules, symmetrical lesions, dryness, and cracks, often leading to pain and bleeding. Treatment of this condition is challenging.[8] Current medical approaches, such as PUVA (Psoralen plus ultraviolet-A radiation), corticosteroids, and immunomodulators, are commonly employed but associated with potential side effects and frequent relapses.[9]

Ayurvedic treatments focus on restoring the balance of Dosha through a holistic approach involving dietary adjustments, lifestyle changes, and the use of herbal and herbo-mineral remedies. This case study examines the implementation of Ayurvedic therapies for the management of Vipadika, with an emphasis on a patient-centered approach utilizing traditional Ayurvedic formulations to treat this prevalent condition.

Case History

On 11 January 2024, a 58-year-old married female patient OPD no. 3766 came to the outpatient department of Rasashastra and Bhaishajya Kalpana at Government Ayurved Hospital, Vadodara, Gujarat, India. The patient was of middle-class socio-economic status, resides with her family in Vadodara, and she is a housewife. She presented a pruritus, and fissure on both soles accompanied by severe pain with oozing of bleeding from fissures, which had persisted for 3 years. She also reported a history of constipation and occasional acidity. With the help of clinical examination and assessment, she was diagnosed with Vipadika. Additionally, she was a known case of hypertension, which was well-managed with allopathic treatment.

Treatment History:The patient, diagnosed with Vipadika (palmoplantar psoriasis), had previously undergone allopathic treatment consisting of Tab. fluconazole 150 mg once daily, Tab. Prednisolone 5 mg twice daily, and a combination of clobetasol and salicylic acid ointment for six weeks. This regimen provided temporary symptomatic relief, but symptoms recurred upon discontinuation of the medications. Upon presentation, the patient exhibited pruritus, xerosis with thickened skin, fissures on both soles, and bleeding from cracks of xerosis, accompanied by severe pain. The patient also has a coexisting condition of hypertension, effectively managed with Tab. Amlodipine 5 mg OD. Additionally, the patient reported a history of excessive consumption of spicy and sour foods, as well as a habit of late-night eating. There was no relevant family history of palmoplantar psoriasis or other similar dermatological disorders.

Clinical Findings:On general examination; the patient had a pulse rate of 68/min, blood pressure of 114/80 mmHg, a temperature of 98.1°F, and a respiratory rate of 19/min; her height was 158 cm,


weight was 71 kg, and Body Mass Index (BMI) was 28.6 kg/m², with clear conjunctiva, a white-coated tongue with no edema in any part of the body. No any lymph nodes were palpable. The laboratory tests showed that the haemoglobin level was 11.4%, and Random Blood Sugar (RBS) 142 mg/dL.

Ashtavidha Pariksha:The Ashtavidha Pariksha findings were as follows: Nadi (pulse) was Vata Kapha. Urine output was 6-7 times per day and 0-1 time per night. The stool was described as Baddha (constipated). The tongue was coated white. The voice was clear. The skin was noted as Sheeta (cool to touch). The vision was normal. The overall body structure (Akriti) was normal.

Diagnostic Assessments:In current study, assessed using criteria such as Panipada Sphutana (Fissure at palm and sole), Kandu (Itching) and Teevra Vedana (Excessive pain). After examinations and assessments, the patient was diagnosed with Vipadika (Palmoplantar Psoriasis).

Criteria of Assessment with scoring

Table 1: Gradation of signs and symptoms of Vipadika

SNSign and SymptomsGrades
01234
1.Panipada Sphutana (Fissures/
cracks)
No cracksCracks on the palm or soles onlyCracks on the palm and solesCracks on the complete foot and complete hand-
2.Kandu (Itching)No itching1-2 times a dayFrequent itchingItching disturbs the sleep-
3.Teevra Vedana (Excessive Pain)No painMild pain of easily bearable nature; comes occasionallyModerate pain, but no difficultyAppears frequently and requires some measures for reliefPain requires medication and may remain throughout the day
4.Auspitz signAbsentLess often bleeding (oozing)Often bleeding but in less amountOften bleeding and excessive-

Therapeutic Intervention

The patient was administered Panchtikta Ghrita, Gandhaka Rasayana, and Avipattikara Churna internally, and the affected areas were cleansed with Panchavalkala Kwatha and Shuddha Tanakana Drava,

followed by exfoliating the feet with a foot scrubber to remove dead skin, and then Jatyadi Malam was applied. Details of medication are given in table 2.

Table 2: Details of given drugs during treatment

SNDrugDoseDuration of treatmentDuration of follow-upAnupanaKala
1.Panchatikta Ghrita20 mlten weeksfour weeksLuke warm waterEmpty Stomach- morning
2.Gandhaka Rasayana2 tab. Thriceten weeksfour weeksLuke warm waterAfter meal
3.Avipattikara Churna4 gten weeksfour weeksLuke warm waterAt night
4.Panchavalkala Kwatha + Shuddha TankanaOnceten weeksfour weeksExternal applicationAt night
5.Jatyadi MalamOnceten weeksfour weeksExternal applicationAt night

Result

The patient was monitored weekly for ten weeks to assess progress and adjust the treatment regimen as necessary. Within two of treatment, the oozing of bleeding was completely relived. After the 4 weeks of treatment (Figure no. 3) significant relief in pain, itching, and dead skin of soles. After eight weeks of treatment, (Figure No. 5) fissures/cracks from both soles disappeared, and the patient could walk without pain. At the end of the ten-week treatment period, the patient reported a significant reduction in all the symptoms (Figure no. 6). The patient was advised to follow Pathtapathya during the whole treatment. Following this period, the patient was observed for an additional four weeks, during which no recurrence of symptoms was, noted (Figure no. 7). Additional follow up of 6 month was also taken in which no recurrence of symptoms was noted (Figure no. 8). Table no. 3 describes the outcome of treatment according to diagnostic criteria.

Table 3: Details of the score of symptoms before and after treatment with follow-up

SNComplaintsBefore Treatment (0 week)After Treatment (10 weeks)Follow up (4 weeks)
1.Panipada Sphutana (Fissures/cracks)200
2.Kandu (Itching)200
3.Vedana (Pain)400
4.Auspitz Sign100

Images of the patient before treatment, after treatment, and after follow-up:

jaims_3629_01.JPG
Figure 1:
Before treatment (Date: 11/01/2024)

jaims_3629_02.JPG
Figure 2:
After 2 weeks of treatment (Date: 25/01/2024)

jaims_3629_03.JPG

Figure 3: After 4 weeks of treatment (Date: 8/02/2024)

jaims_3629_04.JPG
Figure 4:
After 6 weeks of treatment (Date: 15/02/2024)

jaims_3629_05.JPG
Figure 5:
After 8 weeks of treatment (Date: 22/02/2024)

jaims_3629_06.JPG



Figure 6:
After 10 weeks of treatment (Date: 07/03/2024)

jaims_3629_07.JPG
Figure 7:
After 4 weeks of follow-up (04/04/2024)

jaims_3629_08.JPG
Figure 8:
After additional follow-up of 6 months (03/10/2024)

Discussion

Vipadika, an Ayurvedic classification for skin disorders similar to palmoplantar psoriasis, presents with symptoms such as cracking of the skin, dryness, pain, and mild itching, primarily affecting the palms and soles. Palmo-plantar psoriasis affects a notable portion of the population, varying prevalence across regions.

Conventional treatments often offer limited long-term relief due to the chronic and recurrent nature of the condition. In Ayurveda, Vipadika is managed by focusing on balancing the Vata and Kapha Dosha.

The Ayurvedic approach to treating Vipadika emphasizes Shodhana and Shamana Chikitsa followed by Rasayana Chikitsa to restore the balance of Dosha. This case presentation includes a detailed analysis of the patient's demographics, clinical history, symptoms, and prior allopathic treatments, offering a comprehensive view of the patient’s condition and therapeutic journey. The efficacy of combined herbal and herbo-mineral formulations in relieving the symptoms of Vipadika is demonstrated through this approach.

The patient, a 58-year-old female, presents with chronic pruritus and fissures on both soles, accompanied by severe pain and bleeding from the fissures. Previous treatment with allopathic medication provided temporary symptom relief, but recurrence was observed. The proposed Ayurvedic treatment protocol includes the internal administration of Panchatikta Ghrita, Gandhaka Rasayana, and Avipattikara Churna. Additionally, external care involves Prakshalana with Panchavalkala Kwatha combined with Shuddha Tankana, and after Prakshalana use of a foot scrubber to exfoliate dead skin around fissures followed by the application of Jatyadi Malam. Except for Panchatikta Ghrita, all the medicines were in-house standardized production by the Government Ayurved Pharmacy, Rajpipala. Gujarat. Panchtikta Ghrita was advised to purchase of Nagarjuna Pharmacy due unavailability of in-house production. Each component of the treatment is selected based on Ayurvedic principles aimed at restoring the balance of the Doshas and enhancing the patient's immune function.

Probable mode of action of the formulations

Panchatikta Ghrita[10] effectively manages palmo-plantar psoriasis through its key herbs and their active phytochemicals.[11] Patola (Trichosanthes dioica Roxb.) contains triterpenoids and flavonoids that reduce inflammation and oxidative stress.[12] Nimba (Azadirachta indica A. Juss) is rich in quercetin, which inhibits pro-inflammatory cytokines while offering antimicrobial properties.[13] Vasa (Adhatoda vasica Linn Nees) features vasicine, known for its anti-inflammatory and infection-preventing effects.[14] Kantakari (Solanum virginianum Linn.) contains solasodine, enhancing wound healing and reducing inflammation.[15]


Guduchi (Tinospora cordifolia Willd.) is high in tinosporide, which supports detoxification and immune modulation.[16] Haritaki (Terminalia chebula Retz.), Bibhitaki (Terminalia bellirica Roxb.), and Amalaki (Phyllanthus emblica Linn.) contribute tannins and vitamin C, providing antioxidant and detoxifying benefits. Together, these herbs work synergistically to improve psoriasis symptoms.[17]

Gandhaka Rasayana mitigates the effects of Vata and Kapha Dosha due to its Kusthaghna, Kandughna, and Vata-Kaphaghna properties, making it effective against all 18 types of Kustha Roga (skin disorders), including Kshudra Kustha. It primarily acts on the skin and blood, balancing all Dosha and Dhatu.[18]

Gandhaka, with its Ushna Veerya (hot potency) and Katu Vipaka (pungent after digestion), is a potent Kaphaghna and Kledaghna, disrupting the pathogenesis of psoriasis through its Ushna and Katukashay Rasa.[19]

Gandhaka Rasayana's active component, purified sulphur, exhibits anti-inflammatory, keratolytic, antimicrobial, and detoxifying properties. Sulphur reduces skin inflammation, softens thickened skin, prevents infections, and modulates immune responses, helping to manage autoimmune triggers in psoriasis. Its antioxidant action further mitigates oxidative stress, while herbs like Amla, Haritaki, and Guduchi enhance detoxification and liver protection, supporting the long-term management of palmo-plantar psoriasis.[20]

Avipattikara Churna is a herbo mineral compound formulation having clinical significance in the treatment of Amlapitta and Vibandha. Majority of drugs in Avipattikara Churna are possessing Katu, Tikta, Madhura Rasa; Laghu, Ruksha, Tikshna, Snigdha Guna; Ushna-Sheeta Veerya; Madhura and Katu Vipaka. Apart from Sharkara the main ingredient is Trivruta (Operculina turpethum L.). It has Katu, Tikta Rasa; Laghu, Tikshna, Ruksha Guna; Ushna Veerya and Katu Vipaka. It has Bhedana, Rechana and Shothahara properties leading to Pitta Virechana useful in Samprapti Vighatana of Amlapitta and Vibandha.[21]

The local use of Panchavalkala Kwatha[22] as a foot soak effectively manages palmo-plantar psoriasis by addressing inflammation, thickened skin, lesion healing, and infection prevention.

Its astringent, anti-inflammatory, and antimicrobial actions make it a powerful remedy for controlling psoriasis. Tannins and flavonoids in the formulation reduce inflammation by inhibiting cytokines like IL-6 and TNF-α, while the astringent effect dries out lesions and minimizes scaling. Polyphenols combat oxidative stress, and tannins, along with saponins, provide antimicrobial protection. Triterpenoids further enhance wound healing by promoting collagen formation and tissue repair.[23]

Shuddha Tankana Drava is recommended for Varna Shodhana. The Ruksha, Ushna, and Tikshana properties of Shuddha Tankana aid in the debridement of the soles and promote skin regeneration.[24] Sodium borate, the key component of Tankana, provides keratolytic, anti-inflammatory, and antimicrobial effects, while boron, a trace mineral, reduces inflammation and promotes wound healing.[25] The astringent action of Tankana helps reduce moisture, tighten the skin, and prevent further scaling and fissures, with boron enhancing tissue regeneration and aiding the recovery of psoriatic lesions.[26] After Prakshala with Panchavalkala Kwatha and Shuddha Tanakana Drava, the patient was advised to scrub the debridement by using a foot scrubber with low pressure. It helps to remove the dead skin and allows the regeneration of the skin.

Jatyadi Malam is prepared from Jatyadi Taila and Siktha with a ratio of 80:20 as an in-house production of the Government Ayurved Pharmacy, Rajpipala, Gujarat. Jatyadi Malam possesses anti-inflammatory, antimicrobial, wound-healing, and tissue-regeneration properties. It helps alleviate symptoms and promotes healing by enhancing tissue regeneration and repair. Additionally, it provides a moisturizing effect to the skin, reducing itching sensations. The moisture content in Jatyadi Malam prevents skin dryness, supporting overall skin health.[27]

Conclusion

The Ayurvedic treatment protocol comprising internal administration of Panchatikta Ghrita, Gandhaka Rasayana, Avippatikara Churna and topically wash with Panchvalkala Kwatha and Shuddha Tankana and after that use of foot scrubber for scrapping the dead skin followed by Jatyadi Malam demonstrated significant efficacy in managing Vipadika.


The observed improvements in symptoms, coupled with absence of adverse effects and high patient satisfaction, highlight potential of these traditional therapies in treating this common dermatological condition. These findings advocate for further research with larger sample sizes and controlled studies to validate these results and explore broader applicability of Ayurvedic treatments in dermatological and other medical conditions.

Declaration of Patient Consent

The authors declare that they have obtained written consent from the patient, allowing the case, along with relevant images and clinical details, to be published in the journal. The patient is aware that their name and initials will not be disclosed, and every effort will be made to protect their identity, though complete anonymity cannot be assured.

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