Introduction

In Ayurveda, the term "Twacha" originates from the Dhatu "Twach Samvarne," which refers to the skin as the body's covering. Twacha is the seat of Sparshajnanendriya, one of the seats of Vata, and is extensively connected to all five Jnanendriyas.^[1] The Nidanas (causative factors) of Twak Vikaras (skin disorders) most commonly arises due to Mithyahara, Vihara and Manasika Nidanas. Each Dosha vitiation elicit the different Lakshanas in the Twacha. According to Acharya Charaka, Kushta (skin diseases) are categorized into two main types: Mahakushta and Kshudrakushta. Mahakushta is subdivided into seven and Kshudrakushta into eleven types. Mahakushta - Kapala, Udumbhara, Mandala, Rushyajihwa, Pundarika, Sidhma and Kakanaka. Kshudrakushta - Ekakushta, Charmakhya, Kitibha, Vipaadika, Alasaka, Dadru, Charmada, Paama, Visphota, Shataru and Vicharchika.^[2]

Kitibha Kushta is a type of Kshudra Kushta, involving an imbalance of the Tridosha, Rasa, Rakta, Mamsa, and Ambu. Rakta Dusti (blood impurity) is the primary cause for Kushta (skin disorders). Kitibha Kushta is one of the Raktapradoshaja Vikaras caused by the vitiation of Vata and Kapha Doshas in excess, characterized by symptoms such as Shyava Varna (blackish-brown color), Kinakhara Sparsham (rough to the touch), Parusham (dryness), Ruksha Pidika (skin eruptions), and Kandu (itching). The Lakshanas of Kitibha Kushta are similar to those of guttate psoriasis, and based on symptomatology, Kitibha Kushta is correlated with guttate psoriasis.^[3]

Psoriasis is a chronic proliferative and inflammatory condition of the skin. It is characterized by erythematous plaques covered with silvery scales, particularlyover the extensor surfaces, scalp, and lumbosacral region.^[4] The pathophysiology of psoriasis involves infiltration of the skin by activated T cells, which stimulate the proliferation of keratinocytes, leading to an abnormal keratinocyte turnover and resulting in the formation of thick, scaly plaques due to the impaired maturation and retention of corneocytes, and reduced lipid secretion by epidermal cells.^[5] This condition affects both genders equally, with a worldwide prevalence of 1-2%, and can significantly impact the physical, emotional, and psychosocial well-being of affected individuals.^[6]

Initially, he took treatment at a nearby clinic and got temporary relief, again all these symptoms got aggravated with severe itching, so patient visited the Government Ayurveda Medical College and Hospital, where he is admitted for further evaluationandmanagement.

Treatment history

Patient took medications and topical applications whenever symptoms aggravated details of which are not known.

Samajika Vruttanta (Social history)

Living situation - Patient resides alone,
Marital status - Married
Patient social support system - no family members or friends are providing emotional support.
Patient's history of substance use - Patient has a 20-year historyofalcoholuse. Quarter per day, type - local liquor (toddy)

Occupational history

Printing press operator- job Duration -10 hours (10am- 8pm)

Work environment - He is regularly exposed to contaminants, such as odorous inks. Working under AC

Vaiyaktika Vruttanta (Personal history)

• Ahara - Ati Dhadi Sevana with Mamsa, Varaha Mamsa, fish, chicken and mutton (twice in a week). Katu, Ruksha, Abhishyandhi Ahara, Atimadya Sevana, junk food, Adyashana, Vishamashana, Ajeerna Bhojana.
• Vihara - Working under AC (10 hours) Ratrijagarana, Vegadharana, Ati Adwagamana.
• Manasika Nidana - Kroda, Chinta, Shoka
• Agni - Mandagni
• Mala Pravrutti - Incomplete (Kricchra Pureesha)
• Koshta - Krura Koshta
• Nidra - Disturbed due to itching
• Addictions / Habits - Smoking, Alcohol

General Examination

Built - Moderately Built
Pallor - Absent
Nourishment - Well-Nourished

Size and shape: Khara Paryanta,

Configuration: Numerous small drops like papules and plaques

Arrangement of lesion: Scattered, Multiple

Distribution of lesions: Symmetrical upper limbs, lower limbs, chest and back, inguinal region.

Type of skin lesion (Primary); Sookshma Pidaka - Papule, (Secondary) - Shakala - Scale

Palpation:

• Specify – Rooksha, Khara, Parushya,
• Deformity: no deformities observed
• Odour / Srava / Krimi – absent
• Superficial sensation on lesion: hardness of lesions with scaling

Special tests

• Candle grease sign - Present
• Auspitz’s sign - Present
• Koebner’s phenomenon - Absent
• Nikolsky’s sign - Negative

Nidana Panchaka

Ahara - Ati Dhadi Sevana with Mamsa, Varaha Mamsa, fish, chicken and mutton (twice in a week). Katu, Ruksha, Abhishyandhi Ahara, Atimadya Sevana, junk food, Adyashana, Vishamashana, Ajeerna Bhojana.

• Dadhi Sevana and alcohol does Pitta Abhivridhi - Raktadushti
• Viruddahara - meat along with milk - Tridosha Dushti - Raktadushti
• Guru Anna Pana - junk food, pork meat – Kaphaprakopa - Agni Vaigunya, Annavaha, Raktavaha, Mamsavaha Srotodushti.
• Ajeerna, Adyashana, Vishmashana - Tridosha Dushti - Agni Vaishamya - Annavaha, Raktavaha Srotodushti.

Vihara - working under AC (10 hours) Ratrijagana, Vegadharana, Ati Adwagamana.

• Jagarana, Atiadwagamana, Vegadhara causes - Vataprakopa

Manasika Nidana - Kroda, Chinta, Shoka

Purvarupa - Vaivarnya, Kandu, Lomaharsha,

Diagnostic Criteria

The case was diagnosed as Kitibha Kushta based on the presence of Pratyatma Lakshanas explained in our classics, which correlated with the modern medical diagnosis of guttate psoriasis, as assessed using the Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI); accordingly,^[9] the line of treatment described for Kitibha Kushta was adopted in this case.

Lakshana - Shyava, Parusha Pidaka, Kinakara Sparsha, Kandu.

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

Laboratory Investigations

ESR - 45mm/hr.
CBC - findings are normal
LFT - findings are normal
HBsAg - negative
HIV - negative

Diagnosis: Kitibha Kushta based on the Lakshana mentioned in the classics.

Materials and Methods

Sri Jayachamarajendra Ayurveda and Unani Hospital IPD Majestic, Bengaluru, single case study.

Assessment Criteria

Dermatology Life Quality Index (DLQI)

DLQI questionnaire assesses impact of skin conditions on daily life, covering aspects such as Symptoms and feelings, Daily activities, Leisure activities, Work and school, Personal relationships, Treatment effects. Total score, ranging from 0 to 30, indicates level of impairment, with higher scores signifying greater impact on quality of life.^[10]

Psoriasis Area and Severity Index (PASI)^[11]

6. Siddarthaka Snana Churna - externally

Before Treatment

Due to irregular diet, excessive alcohol and tobacco consumption, frequent intake of outside junk food and non-vegetarian meals, work pressure, and lack of family support contributed to the patient's compromised Agni and stress levels, ultimately leading to Kitiba Kushta (Psoriasis). Following a thorough examination and diagnosis, the patient underwent classical Ayurvedic treatment, incorporating Shodhana (detoxification) and Shamana Chikitsa (palliative treatment). As emphasized by Acharya Charaka, correcting Agni was the primary focus ^[12]. To achieve this, Deepana Pachana was administered as a preliminary measure, utilizing Chitrakadi Vati for 2 days. Subsequently, Virechana was performed, followed by Takra Dhara, yielding significant improvements in the patient's condition. Shirodhara, a treatment described in Samhitas for Kushta management, was also administered to further enhance the therapeuticoutcome.

Action of Chitrakadi Vati

Charaka mentions Chitrakadi Vati in the Chikitsasthana, Grahani Adhyaya, where it is used for various purposes, including: Deepana (enhancing stomach fire), Pachana (aiding digestion), Grahi (treating diarrhea), Vibandha (treating constipation), Anulomana, Shulahara, Arshohara, Kusthahara (treating various skin disorders) and Shothahara.^[13]

Action of Arogyavardhini Vati

Arogyavardhini Vati is a Ayurvedic formulation traditionally used to treat Kushta Roga. This medicine exhibits a range of therapeutic properties, including Pitta Virechan, Tridosha Shamak, Deepan, Pachan, Kushthaghna, and Kandughna. By virtue of these properties, Arogyavardhini Vati effectively balances the Tridosha, Agnivardhana (enhances digestive fire), promotes detoxification Bhedana (promotes detoxification), and regulates Vata Dosha (Vatanulomana). Furthermore, its Kushthaghna and Kandughna properties provide relief from Kushtasymptoms.^[14]

Action of Mahamanjishtadi Kashaya and Panchatikta Kashaya

Maha Manjishtadi Kashayam is a potent Ayurvedic medicine utilized in the treatment of Kushta. This formulation, boasting Rakta Shodhana properties, was administered to counteract Sheshadosha Shamana, a critical aspect of Kushta management.

Siddharthaka Snana Choorna

Sidharthaka Snana Churnais an Ayurvedic medicinal preparation in the powder form. It is Kusthahara, Varnya, Twak Doshahara. It improves the complexion of the skin.^[20]

Action of Mahatiktaka Gritha

Mahatiktaka Ghrita possesses a predominance of Tikta and Kashaya Rasas, characterized by Laghu (light) and Snigdha (unctuous) gunas, Sheeta (cooling) Veerya, and Madhura (sweet) Vipaka. These properties render it exceptionally effective in pacifying Pitta and Kapha imbalances. The therapeutic applications of Mahatiktaka Ghrita include the treatment of various conditions, such as: Arsha (hemorrhoids), Vatarakta (gout), Pandu (anemia), Kamala (jaundice), Manoroga (mental disorders), Kustha (skin diseases), Jwara(fever).^[21]

Action of Virechana Dravya

Trivrut Leha is Pittagna. Vatanulomana and Sukha Virechaka.^[22] "Virechana Dravyas, having properties like Ushna, Tikshna, Sukshma, Vyavayi, and Vikasi properties, penetrate deep into the body, reaching the heart due to their potency. They then enter the Dhamanis, circulating throughout the Sthula and Sukshmastrotas. The Agneya Guna of these Dravyas liquefies the accumulated Doshas, breaking them down into smaller particles that circulate freely throughout the Srotas without adhering to any surface, because the Snehana was done in the Purvakarma. These particles then traverse the minute capillaries, moving towards the Koshtha and ultimately reaching the Amashaya. As Virechana drugs predominantly comprise Jala and Prithvi Mahabhutas, they exhibit Adhobhagahara Prabhava, facilitating the elimination of vitiated Doshas fromtheGudamarga.^[23]

Shirodhara with Takra

Takra, possessing five rasas except Lavana, Amla Vipaka, Ushna Virya, and Vata-Kapha-balancing properties. This versatile remedy can be administered both locally and internally to effectively treat Vata-Kapha-dominant Kushta conditions. The high lactic acid content in buttermilk has been scientifically proven to moisturize and reduce the appearance of thickened psoriatic scales. In Kushta, the impairment of Dhatus triggers Dhatu Shaithilyata, a consequence of vitiated Doshas.