Management of Kitibha Kushta (Plaque Psoriasis) with Combination of Ayurvedic Modality-A Case Study
Abstract
Skin diseases are commonly observed due to altered lifestyle, lack of physical exercise, poor hygiene, mental stress and improper food habits. Kushta (Skin diseases) is divided into Maha Kushta (Major skin diseases) and Kshudra Kushta (Minor skin disease). Kitibha Kushta (Plaque Psoriasis) is included in Kshudra Kushta commonly found today, having sign and symptoms similar to Plaque psoriasis. Due to relapsing nature of Plaque psoriasis it needs long duration treatment. Ayurveda provides long lasting results by treating the disease and preventing reoccurrence. In this case study, a 43 years old male came to OPD of Kayachikitsa with chief complaint of Kandu (Itching), dry silvery white patches over left leg treated with Shodhana Chikitsa (Body purification treatment) using Vaman Karma (Therapeutic Emesis) and Shaman Chikitsa (Alleviating treatment) using internally Gandhaka Rasayana, Panchatikta Ghrita and S-kin powder, Shabsoria Oil for external application for 1 month. The PASI score was 14.4. Before treatment, after 15 days it was 7.4 and after 30 days it was reduced to 0. Patient got relief in the symptoms. Better result achieved in this case using Shodhana Chikitsa and Shaman Chikitsa along with Bahirparimarjan Chikitsa (External application).
Keywords
Kitibha, Plaque Psoriasis, Shodhana, Shamana, Bahirparimarjana Chikitsa
Introduction
Psoriasis is a common long lasting auto-immune skin disease with prevalence of 0.44-2.8 percent in India. Psoriasis is typically present as erythematous plaque with silvery scales (Dogra & Yadav, 2010). Most common type of Psoriasis is Plaque Psoriasis in which each lesion separated from other lesions with diameter of millimetres to centimetres. Elbow, knees and lower back are commonly involved areas in Plaque Psoriasis while scalp, nails, flexures, palm are other site. After scraping the surface in plaque psoriasis lesions become red (Colledge, Walker, & Ralston, 2010).
Kushta divided into Maha Kushta and Kshudra Kushta in which all skin diseases in Ayurveda involved (Vidyadhar & Dutt, 2019). Kushta mentioned in Ashtamahagad i.e. difficult to treat by Acharya Charaka (Vidyadhar & Dutt, 2019). Kitibha Kusthais having symptoms like Shyava Varna (discoloration), Kina, Khara Sparsha (rough in touch/scaly), Parushatva (hard), Ruksha Pidika (dry vesicle) with Kandu (Itching) (Vidyadhar & Dutt, 2019). All the sign and symptoms of Plaque psoriasis similar with Kitibha Kushta. Kitibha Kushtha is Vata and Kapha Doshapradhan Disease with Lakshanas (symptoms) of both Dosha. KitibhaKushtha manifests due to deranged physiology of seven factors. They are Vata, Pitta, Kapha, Tvaka
|
Procedure |
Medicine |
Dose |
Duration |
Route |
|
|---|---|---|---|---|---|
|
Purva Karma |
Deepana-Pachana |
TrikatuChurna |
3 gm-3 gm before meal with KoshnaJala |
3 days |
Oral |
|
Snehpana |
Panchatikta Ghrita |
With ascending order from 30 ml to 220 ml At early morning empty stomach with lukewarm water |
7 days |
Oral |
|
|
Sarwanga Snehana followed by Nadi Swedana |
Marichyadi Tail Dashmool Decoction |
Quantity sufficient Quantity sufficient |
For 2 days (After completion of 7 days of Snehapan) |
External application |
|
|
Pradhan Karma |
Vamanakarma |
Madanphal Yoga |
Antaranakha-mushtiMatra |
For 1 day (on 12thDay at morning time after Snehana and Swedana |
Oral |
(skin), Mamsa (muscle), Shonit (blood) and Lasika (Lymphatic system). For treating root cause of disease in Bahudoshavastha of Kushta Shodhana is necessary for elimination of aggravated Doshas from the body as given on Samhita (Vidyadhar & Dutt, 2019). So in this case study KitibhaKushta is managed with Vamanaa long with Shamana Chikitsa.
Case Report
A 43 year old male patient approached with complaints of dry silvery white patches, rough similar to scar tissue over left leg with Kanduin them since 6 months.
Brief history of the Patient
Presenting complaints
A 43 year old male patient who was apparently normal before 6 months, then having complaint of itching over left leg followed by small redish patch which increased gradually and spread dry silvery white patches, rough scar tissue like appearance on left leg (Figure 1). He consulted all local allopathic and Homeopathic physicians before for same complaints, but he did not get satisfactory relief, so for further management he consulted in our hospital.
He had no family history and no past history regarding any skin diseases. No history of any type of allergy before. Due to itching sleep was disturbed. On examination Ashtavidha Pariksha within normal limit except Saam Jivha (Coated tongue) and Malbadhata (Constipation).
Personal History
Ahar (Diet)-Veg, Non-Vegetarian
Nidra (Sleep): Disturbed sleep due to the itching
Vyasan (Habits): Tobacco, MadyaSevana
Occupation: Farmer
Bala: Madhyam
Agni (digestive fire): Agnimandya
Raktadaba (B.P): 110/80 mm of Hg
Skin Examination
1. Inspection:
-
Shape-Round lesions over left leg
-
Color-Silvery White
-
Lesions-Plaques
2. Palpation:
-
Warmth touch with rough texture
Sign
-
Candle Grease Sign - Positive
-
Auspitz Sign - Positive
Laboratory Investigation
-
Blood routine- Normal
-
Rest other system findings was normal
SampraptiGhataka
-
Dosha–Tridosha
|
Medicine |
Dose |
Anupan |
Route |
Duration |
|---|---|---|---|---|
|
GandhakRasayan (250 mg) |
2 tab-2 tab After meal |
KoshnaJala |
Oral |
15 days |
|
PanchatiktaGhrita |
10 ml-10 ml After meal |
KoshnaJala |
Oral |
15 days |
|
S-kin powder with Gomutra |
Quantity sufficient(Q.S.) Twice a day |
- |
Externally over lesions |
15 days |
|
ShabsoriaOil |
Q.S. After bath |
- |
Externally over lesions |
15 days |
2. Dushya –Twaka,Rakta,Mamsa,Lasika
3.Ama (Undigested food particle) –JatharagnijanyaAma
4. Agni–Jatharagni
5.Srotas(Inner transport system of the body)–Rasavaha,Raktavaha
6. Srotodustiprakara –Sanga
7. Rogmarga(Path of Disease)–Bahya
8. Udhbhavasthana –Amashaya
9. Vyaktasthana –Twacha
10. Rogaswabhava–Chirakari
11. Sadhyasadhyaata –Sadhya
Samprapti
Nidan (Causative factor) Sevana like Aharaja-Viharaja-Manasika
(Irregular food habits, Non vegetarian diet, consumption of alcohol, Ativyayam, Atichinta, Ratrijagarana)
Tridosha Prakopa (aggravation)
Twaka, Rakta, Mamsa, Lasika (Dushya)
Sthanasamshraya (localization) in Twacha
Ruksha Pidikawith Kandu
Kitibha Kushta
Materials and Methods
Treatment Plan given
Shodhana Chikitsa and Shamana Chikitsa was given to the patient.
Shodhana Chikitsa
ShodhanChikitsa was given with Vamana Karma in proper sequence of Purvakarama, Pradhankarma, Paschytkarma (Table 3; Table 1).
Shamana Chikitsa
Shamana Chikitsa given using Gandhak Rasayan and Panchtikta Ghrita along with Bahirparimarjan Chikitsa using S-kin Powder with Gomutra (Cow urine) and Shabsoria Oil (Table 3; Table 2).
Paschyat Karma
After Samyaka Vamana Lakshana Dhoompan was given for 5 minutes by each nostril with Aguru stick (Trikamji, 2004). Then Sansarjana Karma was advised for 5 days in the form of Peya, Vilrpi, AkrutMudgaYusha, KrutMudgaYusha, normal diet (Varakunnte, 2010).
Greading-PASI (Psoriasis Area Severity Index) Score
The severity of Psoriasis is estimated by three clinical signs: Severity parameters are measured from none to maximum within each area on the scale of 0 to 4 (Table 5).
|
Sr.no |
Drug name |
Content |
Indication |
|---|---|---|---|
|
1 |
Trikatuchurna |
Sunthi Marich Pipalli |
Deepana, RelieveAma, Shleshmaghna, Medoghna, Kushta |
|
2 |
PanchatiktaGhrita |
Nimba-Azadirechtaindica,Patola-Luffa acutangula, Kantakari-Solanum xanthocarpum, Amruta-Tinospora cordifolia, Adulsa-Adhatoda vasica, Pathya-Terminalia chebula, Bibhitaki-Terminalia bellirica, Amlaki-Emblicaofficinalis), water for decoction, Goghrita |
Deepan, Pachan, Srotoshodhak, Raktaprasadak, Kandughna, Kushtaghna, Varnya |
|
3 |
Marichyadi Tail |
Marich-Piper nigrum, Trivrit-Opercullinaturpethum, Jatamamsi-Nardostachysjatamansi, Haridra-Curcuma longa, Devdaru-Cedrusdeodara, Arka-Calatropisprocera, Kushta-Saussurea lappa, Musta-Cyperusrotundus, Raktachandan-Pterocarpussantalinus, Vishala-Citrulluscolocynthis, Daruharidra-Berbereisaristata, Katutaila-Brassica juncea, Manashila-Purified Realgar, Hartala-Purified orpiment, Gomutra-Cow urine, Gomaya Rasa-Juice of cow dung and Water |
Raktashodhak,Vranaropak, Twachya, Dadru, Shwitra, Kushta |
|
4 |
MadanphalYoga |
MadanphalChurna (Randiadumetorm) VachaChurna (Acoruscalamus) Saindhaw (Rock salt) Honey Milk YashtimadhuPhant (Glycyrrhizaglabra) |
Vamanaopag Vamanaopag Abhishyandi, Shodhak Abhishyandi, Yogavahi Vamanaopag Vamanaopag |
|
5 |
GandhakaRasayana |
ShuddhaGandhaka-Purified Sulphur, Godugdha-Cow milk, Ghee, Chaturjat[Ela-Elettariacardamomum, Twak-Cinnamomumzeylanicum, Tamalpattara-Cinnamomumtamala, Nagkeshar-Mesuaferrea], Guduchi-Tinospora cordifolia, Shunthi-Zinziberofficinalis, Bhrungraj -Ecliptaalba, decoction ofHaritaki, Bibhitaki, Amlaki, Sita -Syrup of suger |
Antibacterial, Antiviral, Antimicrobial, Anti-inflammatory, Antipruritics |
|
6 |
S-kin powder with Gomutra |
Manjistha (Rubiacordifolia) Amalaki, Haritaki, Bibhitaki, Nagermotha, ShuddhaGandhak |
Psoriasis,Eczema, Allergicdermatitis, Acne-pimple, Dandruff |
|
7 |
Shabsoria Oil (Shabnam Company Pvt. limited) |
Bakuchi (Psoraleacorylifolia), Haridra (Curcuma longa), Daruharidra (Berberisaristata), Sarsapa (Brassica nigra), Kushta (Saussurealappa), Karanja (Pongamiapinnata), Chakramarda (Cassia tora) |
KushthaghnaAntibacterial, Antiviral, Antimicrobial, Antifungal, Antiinflammatory, |
|
Sr.no. |
ManikiShuddhi (Measurement) |
AntikiShuddhi (Interpretation) |
VegikiShuddhii (No. of Vega) |
LaingikiShuddhi (symptoms) |
|---|---|---|---|---|
|
Vamana |
Intake-3000 Output-3600 |
PittantakaVamana |
8 |
No bleeding, Kaphachadrika present in vomitus |
|
Plaque characteristic |
Lesion Score |
Lower Limb |
|
|---|---|---|---|
|
Right |
Left |
||
|
Erythema |
0-None 1-Slight 2-Moderate 3-Severe 4-Very severe |
0 |
3 |
|
Induration/Thickness |
0 |
3 |
|
|
Scaling |
0 |
3 |
|
|
Lesion Score Sum (A) |
0 |
9 |
|
|
Percentage area affected |
Involved Area Score |
Grade |
Lower Limb |
|
|---|---|---|---|---|
|
Right |
Left |
|||
|
Area Score (B) |
0% |
0 |
0 |
4 |
|
< 10% |
1 |
|||
|
10 - 29% |
2 |
|||
|
30 - 49% |
3 |
|||
|
50 - 69% |
4 |
|||
|
70 - 89% |
5 |
|||
|
90 - 100% |
6 |
|||
|
Left Leg |
Left Leg |
Left Leg |
|
|---|---|---|---|
|
Before treatment |
After 15 Days |
After 30 Days |
|
|
Skin area involved Grade - A |
4 |
3 |
0 |
|
Erythema (redness) |
3 |
2 |
0 |
|
Induration (thickness) |
3 |
2 |
0 |
|
Desquamation (scaling) E, I, D-B |
3 |
2 |
0 |
|
Total-A x B |
36 |
18 |
0 |
|
Total Body Surface Area |
36x0.4= |
18x0.4 = |
0x0.4 |
|
Total PASI Score |
14.4 |
7.4 |
0 |
|
Sr.No. |
Sign and Symptoms |
Before treatment |
After 15 days |
After treatment |
|---|---|---|---|---|
|
1 |
Erythema |
+++ |
++ |
- |
|
2 |
In-duration |
+++ |
++ |
- |
|
3 |
Desquamation |
+++ |
++ |
- |
|
4 |
Itching |
++++ |
++ |
No Itching |
The body is divided into four sections [Head (H) (0% of a Person’s skin); Arms (A) (20%); Trunk (T) (30%); Legs (L) (40%)]. Each of this area is scored by itself, and then the four scores are combined into the final PASI (Table 7). The percent of skin area involved is evaluated and then converted into a grade from 0 to 6 for each section (Table 6) (Hani, Prakasa, Nugroho, Affandi, & Hussein, 2012).
Discussion
Panchakarma treatment is a novel kind of treatment for different incessant immune system hormonal and degenerative disorders, whereas different kinds of medicines have no palatable answer too similarly helpful for the advancement and safeguarding of wellbeing. Any illness in Ayurveda is dealt with Shodhana, Shaman and Rasayana Chikitsa (Bhende & Parwe, 2020).
Patient had an habit of irregular food intake and other Nidanas like MadyaSevana, MamsaSevana, AdhikaVyayama, Ratrijagarana, AdhikaChinta leads to KitibhaKushta. Chikitsa planned depending on the Lakshans (Symptoms) and Nidanas like Deepana, Pachana, Shodhana with Vamana following the sequence of Purvakarma, Pradhankarma and Paschyatkarma along with Shamanoushadhi, Bahirparimarjan Chikitsa (external application) were given. All this equally help to reduce sign and symptoms of KitibhaKushta (Table 8 & Figure 2)
Probable Mode of Action of Shodhan (Vamanakarma)
In Purvakarma Dipana- Pachana (Appetizer-digestant) was given with Trikatu Churnafor 3 days which mainly acts as an Agni Vardhaka, Amadosha Nashaka (Government of India, 2011). AbyantarSnehapana (Internal oleation) was given in increasing order with PanchatiktaGhritafor 1 week which pacify VataDosha. It subside Kharata (Dry scaling), Parushataas well as Shyawa Varna in KitibhaKushta (Government of India, 1978). MarichyadiTail was used for Sarvanga Abhyanga. It is Raktashodhaka, Vranaropaka, Twachyamainly reduces dryness and provides hydration to skin and improves the blood circulation (Jully, 2013).
After SarwangaSnehana, SarwangaSwedana given in the form of NadiSwedan (Bramhananda, 2015). It removes Srotasaob struction. Due to Swedana, Doshas gets liquifies and came from Shakha to Koshta for easy elimination with the help of Shodhana.
In Pradhan Karma Vaman was given (Table 4) with Madanphal Yoga (Vidyadhar & Dutt, 2019). Followed by SamsarjanKarma. For diseases of KaphaDoshaVamana is useful as it given in Samhitas. Due to predominance of KaphaDosha in KitibhaKushta, Vamana was given. Vamana purifies body through there peutice mesis, increase Agni, prevents relapsing nature of disease by strengthening Immune system of body. SamsarjanaKramaworks on Agni Dipana.
After Vamana procedure VataPrako occurs, so for Vata Shamana Panchatikta Ghrita was given as Abhyanter Snehapana which is indicated in Kushta. Kushta Rogacame underRaktapradoshaj Vikara cording to Acharya Charaka. Vasa, Nimba, Patola and Guduchi brakes pathogenesis of Kushta, due to potent hepatoprotective action.
Mode of action of Gandhaka Rasayana
Gandhaka Rasayana (Sashtri, 1983) is broad spectrum medicine useful in number of skin diseases like psoriasis, eczema, itching due to it’s anti-microbial, anti-bacterial and anti-viral properties. Gandhaka Rasayana improves digestion and complexion of Skin. Main ingredient i.e. Purified Sulphur acts on skin and mucous membrane. With mercury purified Sulphur used in many diseases. Internal and external both route of purified Sulphur useful to treat skin disease.
Mode of action of Panchatikta Ghrita
Panchatikta Ghrita is explained in Bhaishajyaratnavali, In Kushtadhyaya. Ingredients of it having Kushtaghna property. Goghritais Vata-pitta Shamaka, Twachya, useful in healing and has a “Samskarasya Anuvartanam” property (without losing own property, assimilates the properties of other substance with which it is processed). So Panchtikta Ghrita becomes more effective in psoriasis.
Mode of action of S-kin powder with Gomutra
It is very useful for topical skin infection and also a drug of choice to wash all over body. It treats all skin diseases due to it’s anti-microbial, anti-bacterial, anti-fungal, anti-viral properties. It is Raktashodhaka, Vranaropaka, Twachya reduces Kandu. When the paste of powder made with gomutra applied on skin get penetrated through skin layer. Gomutra is strong, piercing, alkaline, astringent, Vatakaphashamaka used for treatment of skin disease.
Mode of action of Shabsoria Oil
Shabsoria oil useful in skin diseases like psoriasis, itching, eczema due to it’s Kushtaghna property. Ingredients of Shabsoria oil pacify Tridosha, moisturizes the skin and improves skin complexion.
Before treatment Erythema, In-duration, Itching and Desquamation of the lesion over left leg was severe. Initially PASI score was 14.4,15 days later it was reduced to 7.4 and after treatment it was reduced to 0. By following treatment protocol like Shodhana (Vaman), Shamana (Internal medications) and Bahirparimarjan Chikitsa patient got relief in his symptoms.
Conclusion
In Kushta Chikitsa both Shodhana and Shamana therapy plays very important role. Symptoms of Plaque psoriasis is similar with Kitibha Kushta. This case study concluded that Kitibha Kushta can be cured with Vaman Karma followed by Shamana Chikitsa using internally Gandhaka Rasayana, Panchatikta Ghrita and externally application of Shabsoria oil, S-kin powder with Gomutra for 15 days. By combination of Ayurvedic Modalities like Shodhana Chikitsa with Shaman Chikitsa (along with Bahirparimarjan Chikitsa) better results can be achieved.
Acknowledgement
I acknowledge the full cooperation and encouragement of my teachers Dr. Sourabh Deshmukh Associate Professor & Dr. Vinod Ade Professor, Department of Kayachikitsa, MGAC for sparing their precious time. The endless support they have bestowed upon me have been the guiding force behind me. Their idealist approach, faith in the science commitment toward work and anticipation made this work a success and it will always motivate me in future work.
We proclaim that the manuscript is original and has not published yet and is not currently being considered for publication. We declare that the manuscript is original and has not published before and is not currently being considered for publication to another journal.
Funding Support
The authors declare that they have no funding support for this study.
Conflict of Interest
The authors declare that there is no conflict of interest for this study.