E-ISSN:2456-3110

Case Report

Vatarakta

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 10 OCTOBER
Publisherwww.maharshicharaka.in

Ayurvedic Strategies for Managing Psoriatic Arthritis [Vatarakta] - A Case Study

Jyothirmai M1*, Sowmyashree UP2, Gopalakrishna3
DOI:10.21760/jaims.9.10.45

1* Mandre Jyothirmai, Post Graduate Scholar, Dept of Kayachikitsa, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India.

2 Sowmyashree UP, Associate Professor, Dept of Kayachikitsa, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India.

3 Gopalakrishna, Professor and HOD, Dept of Kayachikitsa, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India.

Psoriatic arthritis [PsA] is a chronic and progressive inflammatory disease that impacts the skin, joints, and entheses. In 60-70% of cases, psoriasis precedes joint disease in 15-20% of cases, In India the prevalence has been reported as 8.7%. In Ayurveda, PsA can be compared with Vatarakta. Vata and Rakta Dosha play a significant role in Vatarakta. However, it’s important to note that the pathogenesis of Vatarakta involves an amalgamation of deeper Dhatu. A 48-year-old female patient presented with the complaints of severe itching, pinkish rashes characterized by silvery scaling behind the right ear and over the chest, which had persisted for four years. Additionally, the patient experienced pain and stiffness in the joints of her hands [specifically, PIP & DIP joints] and lower back for the past two months. Despite having previously undergone various topical and oral treatments, there were no discernible signs of improvement. The patient was diagnosed with PsA, and subsequently treated with a regimen included Shodhana, Shamana, and Pathya-Apathya. After undergoing Classical Ayurvedic management, the patient experienced improvement in symptoms. In Ayurveda by addressing the root cause through Shodhana, Shamana and Pathya-Apathya offers valuable insights for managing PsA.

Keywords: Ayurveda, Psoriatic arthritis, Vatarakta, Virechana

Corresponding Author How to Cite this Article To Browse
Mandre Jyothirmai, Post Graduate Scholar, Dept of Kayachikitsa, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India.
Email: 		Jyothirmai M, Sowmyashree UP, Gopalakrishna, Ayurvedic Strategies for Managing Psoriatic Arthritis [Vatarakta] - A Case Study. J Ayu Int Med Sci. 2024;9(10):271-278.
Available From
https://jaims.in/jaims/article/view/3769

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-09-08 2024-09-18 2024-09-28 2024-10-08 2024-10-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
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© 2024by Jyothirmai M, Sowmyashree UP, Gopalakrishnaand 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

Psoriatic arthritis [PsA] is a chronic, progressive inflammatory disease that affects the skin, joints, and entheses.[1]

PsA has both Auto-immune and Auto-inflammatory features[2] occurring in individuals with Psoriasis. The duration and severity of psoriasis increase the likelihood of developing Psoriatic arthritis [PsA].

The association between arthritis and psoriasis was recognized in the 19th century. In 1964, psoriatic arthritis [PsA] was comprehended as a separate disease by the American Rheumatism Association [Now the American College of Rheumatology].[3] In India, the prevalence of PsA has been reported as 8.7%.[4]

The disease can manifest either in childhood or at later ages but typically begins in the fourth or fifth decade and the occurrence is roughly equal in both genders. In 60-70% of cases, psoriasis leads to joint disease, In 15-20% of cases the arthritis precedes the onset of Psoriasis and which can pose challenges for diagnosis as well as management.[5] The specific ICD-10-CM code L40.52 is designated for indicating the diagnosis of PsA according to WHO.[6]

In Ayurveda, most skin disorders are grouped under one comprehensive chapter called Kustaroga [Skin disorders], whereas joint disorders can be expounded under Sandhigata Vata, Amavata, Vatarakta and many more. Based on similarities in Lakshanas, Upadrava. PsA can be relating to Vatarakta. Acharya Charaka has distinguished between two types of Vatarakta, namely Uttana and Gambhira Vatarakta. Here Uttana Vatrakata affects Twak, Rakta and Mamsadhatu and exhibits clinical features such as Kandu, Daha and Twak Vivarnata which share similarities with conditions like Kushtaroga. In chronicity, aggravated Doshas invade Asthi and Majja Dhatu where manifestations like Sandhi Shotha, and Sandhi Stabdata are considered as Gambhiravatarakta resembling PsA.[7]

An approach was made based on Dosha-Dushya Sammurchana, a comprehensive strategy comprising Shodhana, Shamana and Nidana Parivarjana is essential for the effective management of this condition.

Case Report

A Female patient aged about 48years native of Pune, Maharashtra, India who is a Homemaker by occupation presented at OPD of Kayachikitsa, Sri Sri College of Ayurvedic Science and Research Hospital, Bangalore on 04/12/2021 with the complaint of Severe Itching, Pinkish rashes with silvery scaling behind the right ear and over chest since 4years associated with pain and stiffness in the joints of her hands [specifically, PIP & DIP joints] and lower back for the past two months. The clinical events of the patient is given in Table 1.

Table 1: Clinical events, Management and Observation

YearClinical EventsManagement and Observations
May 2017Severe Itching, Pinkish rashes with silvery scaling behind the right earThe patient initially consulted a Physician who diagnosed her with plaque psoriasis. The prescribed treatment included a two-month course of internal medications and the use of topical steroids. Unfortunately, detailed information about the specific medications and their dosages is not available.
After 2 months of treatment, the patient has experienced mild Improvement in rashes, itching and scaling of skin so she stopped taking all medications.
In 2019The symptoms were recurrent since then she has been taking the same medications including Topical steroids without seeking consultation.
October-December 2021The patient started experiencing Insidious pain in the Lower back followed by hands [PIP, DIP] with recurrent swelling and stiffness which lasted for the next 2months and significantly impacted her day-to-day activities. In addition to joint pains, the skin rashes began spreading to the scalp, originating from the posterior right ear with severe Itching and increased silvery plaques

Personal History

Ahara - Mixed diet [rice, chapati, fish, chicken, curd, dosa etc]
Mala - Prakruta, once/day, clear
Mutra - 4-5 times/day 0-1time at night
Vihara - Divaswapna [1-2hrs /day]
Nidra - Nidralpata due to Itching.
Psychosocial history - Chinta, Shoka due to family issues
Family history - Mother is K/C/O Psoriasis.
Past medical history - No contributory factors related to the current health condition.
Obstetric history - Menopause at age of 44 years.


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Srotopareeksha

The Physical examination, Systemic Examination and Local examinations mentioned in Table 2 and Table 3

Clinical Examination and Findings

Physical Examination

The General examination was normal and no significant abnormalities were noted.

  • Built - Mesomorphic
  • Nourishment - Moderately nourished
  • Cyanosis - Absent
  • Clubbing - Absent
  • Edema - Absent
  • Pallor - Absent
  • Icterus - Absent
  • Lymphoedenopathy - Absent
  • BP - 130/80mmHg
  • PR - 68/min
  • RR - 16/min
  • SpO2 - 98%
  • BMI - 20.2kg/m2

Systemic Examination

CNS - patient was conscious well oriented to time place and person and all cranial nerves are intact.
CVS - S1 S2 heard on added sounds.
RS - Normal Bronchovescicular sounds were heard over bilateral chest walls.

Local Examination and Findings

Skin examination

On Inspection

Site - posterior aspects of right ear pinna and over the chest
Colour of the lesion - Dry thin silvery white scales.
Number of lesions - one large lesion 7-8cm
Distribution - asymmetrical
Arrangement - widespread lesion
Surface features - plaques ++
Discharge - Bleed on Itching
Auspitz Sign - Present
Candle grease sign - Seen

On Palpation

Surface palpation - Uneven/rough
Temperature - Warmth on touch
Moisture - Dryness [Present]

Musculoskeletal examination

On Inspection

Swelling and Redness - Present [+] in [PIPJ and DIPJ] Index and middle finger of left hand.
Stiffness - moderate [++] in bilateral hand joints.
No swelling, Discolouration, scars or deformity - over the Lower back

On palpation

Tenderness - Mild [+] over Lower back [L4-L5, L5-S1]
Moderate [++] both hand joints PIPJ and DIPJ more in left hand fingers.
Warmth - Normal on touch.
Visual Analogue Scale [VAS] Score - 6.

Nidana Panchaka

Nidana: Dhadhi Atisevana, Milk rice with added salt, Diwaswapna, Vegadharana, Chinta, Shoka

Poorvarupa: Kandu, Sweadaabhava.

Rupa: Kandu, Twak Vaivarnyata, Sandhi Stabtata, Sandhi Shola, Sandhi Shotha

Upashaya: Application of ointment

Anupashaya: Cold weather, Stress

Samprapti: The probable Samprapti of this case is mentioned in Fig. 1.

jaims_3769_01.JPG


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Samprapti Ghataka

Samprapti Ghataka is mentioned in Table 5

Table 5: Samprapti Ghataka

दोषVata Pradhana Tridosha Dusti
दूष्यTwak, Rasa, Rakta, Lasika, Asthi
अग्निदुष्टिVishamagni Janya Aama
स्रोतस्Rasavaha, Raktavaha,Mamsavaha,Asthivaha.
स्रोतोदुष्टिVimarga Gamana, Sanga
उद्भवस्थानAmapakwashaya
व्यक्तस्थानTwak
अधिष्ठानKarna, Urah Pradesha, Sandhi Pradesha [Janu,Kati,Hastha]
स्वभावChirakari
प्रभावYapya
रोगमार्गBahya and Madyama

Table 6: Treatment timeline

DateChikitsaAushadhiMatraRouteKala
4/12/2021 to 6/12/21Deepana & PachanaChitrakadi Vati1 TID with lukewarm water [Before food]Oral3 days
7/12/21 to 10/12/21SnehapanaMahatiktaka Ghritam1st day - 30ml
2nd day - 60ml
3rd day - 90ml
4th day - 120ml
Daily at 7 a.m. on [Empty stomach]		Oral4 days
11/12/21 to 13/12/21Sarvanga Abyanga & Dhara
Sthanika Valuka Sweda		Brihat Saindhavadi Tailam + Mahamarichyadi Tailam
Aragwada Kashayadhara		Quantity SufficientExternal application3 days
14/12/21VirechanaGandharvahastadi Eranda Tailam60ml [On an empty stomach]Oral1 day

Timeline

Vatarakta Based on the clinical presentation, the patient was diagnosed with PsA, which can be correlated to in Ayurveda.

Thus, the management of Vatarakta [PsA] focused mainly on two key aspects i.e., Antah Parimarjana and Bahirparimarjana Chikitsa. Additionally, the patient was advised to follow Nidanaparivarjana. Treatment timeline mentioned in Table 6 & Table 7.

First Phase of Management

The patient's treatment was planned for Classical Virechana [Purgation therapy] to eliminate the Doshas.

Poorvakarma

As a part of Poorvakarma [Preoperative procedure], Chitrakadi Vati was given for Deepana, Pachana for 3 days and Snehapana was given [Till Samyaksnigdha Lakshanas] with Mahatiktaka Ghritam for 4 days.

During Vishrama Kala Abyanga with Brihat Saindhavadi Tailam + Mahamarichyadi Tailam followed by Sarvanaga Dhara and Sthanika Valuka Sweda over painful joints.

Pradhana Karma

On December 14, 2021, The Patient underwent Virechana. Gandarvahastadi Eranda Tailam - 60ml was administered at 8:00am. A total of 13 Vegas were observed during the Virechana process.

Paschat Karma

Following Virechana, the patient was advised to follow Peyadi Samsarjana Krama for the next 3days

Table 7: Treatment plan and Outcome

SNTimelineTreatment planClinical outcome
1.During admission
04/12/21-14/12/21		Classical VirechanaReduction in Pinkish rashes, Severe Itching silvery plaques. Mild reduction in Multiple Joint pain.
2.First follow-up 15/12/22 To 05/01/22AushadhaMatra, Anupana & Aushadha Sevana KalaThere has been Mild reduction in Silvery plaques and Itching Persistent pinkish rashes There has been a Mild reduction in lowerback pain Stiffness in the small joints continued,
The swelling was recurrent.
Rasnasaptaka Kashayam20ml Twice daily Before food with lukewarm water
Amrutadi Guggulu2Tab Twice daily after food
Panchatiktaghrita Guggulu2 Tab Twice daily after food
Arogyavardhini Vati1 Tab twice daily
Vedanantaka liniment + Brihatsaindhavadi TailamFor local application 1/2hr before bath over painful joints followed by lukewarm water bath
777 oilFor local application After the bath over skin rashes
D-Sora soapfor Bath

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3.2nd follow-up 06/01/22 To 26/01/22AushadhaMatra, Anupana & Aushadha Sevana KalaComplete reduction in the scaling of skin and Itching Pinkish rashes Reduced and multiple joint pain reduced Swelling was absent
Rasnasaptaka Kashayam20ml Twice daily Before food with lukewarm water
Amrutadi Guggulu2 Tablets Twice daily After food
Panchatiktaghrita Guggulu2 Tablets Twice daily After food
Vedanantaka liniment oil + Brihatsaindhavadi TailamFor Local application 1/2hr before bath over painful joints followed by lukewarm water bath
777 oilFor local application After the bath over skin rashes
D sora soapfor Bath
Pathya - Apathya
Pathya AharaApathya AharaPathya ViharaApathya Vihara
Purani Shali, Amalaka, Laghu Ahara, Ghrita, Godhuma, Tikta Rasa AharaViruddahara Sevana [milk rice with added salt], Dadhi Atisevana, Ati-Amlarasa, Guru AharaAbyanga Laghu VyayamaChinta, Shoka, Diwaswapa, Vegadharana,

Discussion on Treatments

The Shodhana can be achieved in this condition by adopting the principle of Classical Virechana. Mode of action of Snehapana - By Sukshma Guna of Sneha easily penetrates the Sukshma Srotas and also does Sroto Vishodhana, thus aiding in bringing the Doshas back to Koshta.[8]

Mode of action of Abyanga and Swedana

It is practised as a Dinacharya and Rtutucharya in healthy persons, in diseased it is used for Shamana Chikitsa and also as a part of Poorvakarma before the administration of Shodhana.

  • Improves the tone and strength of muscles, and improves the mobility of joints.
  • Swedana relieves Sthamba, Shotha and Shoola.[9]

Discussion on Shamanoushadhis

Rasnasaptaka Kashayam

This formulation contains Rasna [Pluchea lanceolata], Amruta [Tinospora cordifolia], Aragwadha [Cassia fistula], Devadaru [Cedrus deodara], Gokshura [Tribulus terrestris], Eranda [Ricinus communis], Punarnava [Boerhavia diffusa] most of these components exhibits properties such as Amapachana, Shoolahara and Sthambahara which are Anti-inflammatory, Analgesics, Immuno-modulators.[10]

Amrutadi Guggulu[11]

Amrutadi Guggulu is primarily indicated for conditions such as Kustha, Amavata and Vatarakta. It Includes Amruta [Tinospora cardifolia], Guggulu [Commiphora mukul], Triphala,

Trikatu [Zinziber officinale, Piper longum, Piper nigrum] and Trivrut [Operculina turpethum]. This formulation exhibits Tridoshahara properties, acts as a Raktashodhaka and possesses Anti-Inflammatory and Immunomodulatory actions, so it is very helpful in this condition. The drugs like Amruta, Shunti, Vibhitaki, Amalaki provide relief in Kandu and Shotha.

Panchatikta Ghrita Guggulu [PTG Guggulu][12]

This formulation composed of several key ingredients, including Nimba [Azadiracta indica], Patola [Trichosanthes dioica], Vyaghri [Solanum xanthocarpus], Guduchi [Tinospora cardifolia], Vasa [Adathoda vasica], Guggulu [Commiphora mukul] Jala [Water] and Ghrita [Ghee]. Notably, Guduchi and Patola within this composition serve as Anti-oxidants, while Nimba, Vasa and Vyaghri exhibit proven Anti-Histamine, Anti-Inflammatory properties. Guggulu and Guduchi have Rasayana properties.[12]

Vedanantaka Liniment

It is composed of several Tailas, Pinda Tailam, Narayana Tailam, Sarala Taila, Dhanwantaram Taila, Devadaru Taila, Gandha Taila, Shallaki Taila, Lavanga Taila, Tailaparni Taila these oils collectively possesses anti-inflammatory and analgesic properties.

Arogyavardhini Vati

Arogyavardhini Vati contains Haritaki [Terminalia chebula], Vibhitaki [Terminalia bellirica], Amalaki [Emblica officinalis], Shuddha Guggulu [Commiphora mukul], Chitrakamula [Plumbago zelanica], Shudha Shilajatu, katuki [Picrorrhiza kurroa].


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It is Tridoshashamaka, Includes several pharmacological actions like Deepana-Pachana, Kustagna, Sarvarogahara. Especially Drugs like Parada [Mercury], Shilajatu have Rasayana action whereas Gandhaka, Triphala are best useful in skin diseases, Loha Bhasma is Yakrit Uttejakara etc. It also contains drugs which improve the liver functioning.[13]

777 oil

It includes Sweta Kutaja [Wrightia tinctoria] and Narikela Tailam [Cocos nucifera] Anti-inflammatory and Anti-microbial properties mainly Indicated in Visarpa, Kustha Roga.

Results

Results of before and after treatment in Table 8.

Table 8: Results

Clinical featuresBefore treatment 4/12/2021After treatment 26/01/2022
Silvery scaling, pinkish rashes Itching over right ear and over chestPresentReduced
Stiffness over bilateral hand joints++Reduced
Swelling and Redness in Index and middle finger of left hand [PIP & DIP]+-
TendernessLowerbackMild [+]Reduced
Hand jointsModerate [++]
VAS score63
Pasi score4.21.2

jaims_3769_02.JPG
Figure 2: Skin lesion before treatment

jaims_3769_03.JPG
Figure 3: After Virechana

jaims_3769_04.JPG
Figure 4: After 1st follow-up

jaims_3769_05.JPG
Figure 5: 2nd follow-up

Conclusion

Vatarakta, a condition in Ayurveda shares a striking resemblance with PsA in contemporary science. Both conditions involve Inflammation, Joint pain, and Immune system dysregulation. The Ayurvedic perspective on Vatarakta emphasizes the importance of balancing Dosha, this case study provides a noteworthy foundation by addressing the root cause through Shodhana, Shamana and Pathya-Apathya offers valuable insights for managing this condition.

Patient perspective

The patient reported experiencing relaxation and an overall improvement in the quality of life after receiving Ayurvedic medications.

Patient consent

Written consent was obtained from the patient for publication of this case.

References

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