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\def\RunningAuthor{Ashvini Dinesh Pardhekar}
\firstPage{2304}
\articleType{Case Report}
\receivedDate{05 Oct 2020}
\acceptedDate{10 Nov 2020}
\revisedDate{08 Nov 2020}
\journalVolume{2020, 11 (SPL4)}
\journalDoi{ijrps.v11iSPL4.4458}
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\title{Management of \textit{Kitibha Kushta} (Plaque Psoriasis) with Combination of Ayurvedic Modality-A Case Study}
\author{Ashvini~Dinesh~Pardhekar\textsuperscript{*},  
            Sourabh~Deshmukh, 
            Vinod~Ade~\\[5pt]{Department of Kayachikitsa, Mahatma Gandhi Ayurved College, Hospital \& Research Centre, Constituent College of Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha-442001, Maharashtra, India}}

\begin{abstract}
Skin diseases are commonly observed due to altered lifestyle, lack of physical exercise, poor hygiene, mental stress and improper food habits. \textit{Kushta } (Skin diseases) is divided into \textit{Maha Kushta } (Major skin diseases) and \textit{Kshudra Kushta} (Minor skin disease). \textit{Kitibha Kushta } (Plaque Psoriasis) is included in \textit{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 \textit{Kandu } (Itching), dry silvery white patches over left leg treated with \textit{Shodhana Chikitsa } (Body purification treatment) using \textit{Vaman Karma } (Therapeutic Emesis) and \textit{Shaman Chikitsa} (Alleviating treatment) using internally \textit{Gandhaka Rasayana}, \textit{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 \textit{Shodhana Chikitsa } and \textit{Shaman Chikitsa } along with \textit{Bahirparimarjan Chikitsa } (External application).  
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Kitibha,\newline Plaque Psoriasis,\newline Shodhana,\newline Shamana,\newline Bahirparimarjana Chikitsa
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Ashvini~Dinesh~Pardhekar~\\ Phone:\ 9075591491~\\  Email:\ ashupardhear@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{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 \unskip~\citep{1028134:21602243}. 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 \unskip~\citep{1028134:21602245}. 

\textit{Kushta }divided into \textit{Maha Kushta} and \textit{Kshudra Kushta} in which all skin diseases in Ayurveda involved \unskip~\citep{1028134:21602241}. \textit{Kushta} mentioned in \textit{Ashtamahagad} i.e. difficult to treat by Acharya Charaka \unskip~\citep{1028134:21602244} \textit{. Kitibha Kustha}is having symptoms like \textit{Shyava Varna } (discoloration)\textit{, Kina, Khara Sparsha }(rough in touch/scaly)\textit{, Parushatva } (hard)\textit{, Ruksha Pidika } (dry vesicle) with \textit{Kandu (}Itching) \unskip~\citep{1028134:21602235}. All the sign and symptoms of Plaque psoriasis similar with \textit{Kitibha Kushta}. \textit{Kitibha Kushtha} is \textit{Vata} and \textit{Kapha Doshapradhan} Disease with \textit{Lakshanas } (symptoms) of both \textit{Dosha}. \textit{KitibhaKushtha } manifests due to deranged physiology of seven factors. They are \textit{Vata}, \textit{Pitta}, \textit{Kapha}, \textit{Tvaka }


\begin{table*}[!htbp]
\caption{\boldmath {Table showing protocol of \textit{Shodhana Chikitsa}} }
\label{tw-e129cfe3522a}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.08799999999999997\linewidth-2\tabcolsep}p{\dimexpr.1825\linewidth-2\tabcolsep}p{\dimexpr.15850000000000001\linewidth-2\tabcolsep}p{\dimexpr.244\linewidth-2\tabcolsep}p{\dimexpr.2245\linewidth-2\tabcolsep}p{\dimexpr.1025\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{2}{p{\dimexpr(.27049999999999997\linewidth-2\tabcolsep)}}{\cAlignHack Procedure} & Medicine & Dose & Duration & Route\\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.08799999999999997\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{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  \mbox{}\protect\newline At early morning empty stomach with lukewarm water  &
  7 days  &
  Oral \\
 &
  Sarwanga Snehana   \mbox{}\protect\newline followed by Nadi Swedana  &
  Marichyadi Tail  \mbox{}\protect\newline Dashmool Decoction  &
  Quantity sufficient  \mbox{}\protect\newline Quantity sufficient  &
  For 2 days  \mbox{}\protect\newline (After completion of 7 days of Snehapan)  &
  External application \\
Pradhan Karma  &
  Vamanakarma  &
  Madanphal Yoga  &
  Antaranakha-mushtiMatra  &
  For 1 day (on 12\ensuremath{^{th}}Day at morning time after Snehana and Swedana  &
  Oral \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
(skin), \textit{Mamsa } (muscle), \textit{Shonit } (blood) and \textit{Lasika } (Lymphatic system). For treating root cause of disease in \textit{Bahudoshavastha} of \textit{Kushta Shodhana} is necessary for elimination of aggravated \textit{Doshas} from the body as given on Samhita \unskip~\citep{1028134:21602231}. So in this case study \textit{KitibhaKushta} is managed with \textit{Vamana}a long with \textit{Shamana Chikitsa}. 

\textbf{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 \textit{Kandu}in them since 6 months. 

\textbf{Brief history of the Patient}

\textbf{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~\ref{f-9f9f5ef90330}). 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 \textit{Ashtavidha Pariksha} within normal limit except \textit{Saam Jivha } (Coated tongue) and \textit{Malbadhata} (Constipation). 

\textbf{Personal History }

\textit{Ahar} (Diet)-Veg, Non-Vegetarian 

\textit{Nidra }(Sleep): Disturbed sleep due to the itching  

\textit{Vyasan} (Habits): Tobacco, \textit{MadyaSevana}

Occupation: Farmer

\textit{Bala}: \textit{Madhyam}

\textit{Agni }(digestive fire)\textit{: Agnimandya}

\textit{Raktadaba }(B.P): 110/80 mm of Hg 

\textbf{Skin Examination }

1. Inspection: 


  
  \begin{enumerate}
  \item \relax Shape-Round lesions over left leg 
  \item \relax Color-Silvery White
  \item \relax Lesions-Plaques
  \end{enumerate}
  2. Palpation: 


  
  \begin{enumerate}
  \item \relax Warmth touch with rough texture
  \end{enumerate}
  \textbf{Sign}


  
  \begin{enumerate}
  \item \relax Candle Grease Sign - Positive
  \item \relax Auspitz Sign - Positive
  \end{enumerate}
  \textbf{Laboratory Investigation} \textbf{\space }


  
  \begin{enumerate}
  \item \relax Blood routine- Normal
  \item \relax Rest other system findings was normal 
  \end{enumerate}
  \textit{\textbf{SampraptiGhataka}}


  
  \begin{enumerate}
  \item \relax \textit{Dosha}{\textendash} \textit{Tridosha}
  \end{enumerate}
  
\bgroup
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\caption{\boldmath {Silvery scaly lesion over left lower limb}}
\label{f-9f9f5ef90330}
\end{figure}
\egroup

\begin{table*}[!htbp]
\caption{\boldmath {Table showing Medicine given after \textit{SansarjanaKrama}} }
\label{tw-bae8b47e3bcc}
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\tbltoprule \rowcolor{kwdboxcolor}Medicine  & Dose  & Anupan  & Route   & Duration \\
\tblmidrule 
GandhakRasayan  \mbox{}\protect\newline (250 mg)  &
  2 tab-2 tab \mbox{}\protect\newline After meal &
  KoshnaJala  &
  Oral  &
  15 days  \\
PanchatiktaGhrita  &
  10 ml-10 ml \mbox{}\protect\newline After meal &
  KoshnaJala  &
  Oral  &
  15 days  \\
S-kin powder with Gomutra  &
  Quantity sufficient(Q.S.)  \mbox{}\protect\newline Twice a day &
  -  &
  Externally over lesions  &
  15 days  \\
ShabsoriaOil   &
  Q.S. \mbox{}\protect\newline After bath &
  -  &
  Externally over lesions  &
  15 days  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
2. \textit{Dushya} {\textendash}\textit{Twaka,Rakta,Mamsa,Lasika} \textit{\space }

3.\textit{Ama }(Undigested food particle) {\textendash}\textit{JatharagnijanyaAma } \textit{\space }

4. \textit{Agni{\textendash}Jatharagni}

5.\textit{Srotas}(Inner transport system of the body){\textendash}\textit{Rasavaha,Raktavaha} \textit{\space }

6. \textit{Srotodustiprakara} {\textendash}\textit{Sanga} \textit{\space }

7. \textit{Rogmarga}(Path of Disease){\textendash}\textit{Bahya} \textit{\space }

8. \textit{Udhbhavasthana} {\textendash} \textit{Amashaya}

9. \textit{Vyaktasthana {\textendash}Twacha}

10. \textit{Rogaswabhava}{\textendash} \textit{Chirakari}

11. \textit{Sadhyasadhyaata} {\textendash} \textit{Sadhya}

\textit{\textbf{Samprapti}}

\textit{Nidan }(Causative factor) \textit{Sevana} like \textit{Aharaja}-\textit{Viharaja}-\textit{Manasika}

(Irregular food habits, Non vegetarian diet, consumption of alcohol, \textit{Ativyayam}, \textit{Atichinta}, \textit{Ratrijagarana}) 
\begin{eqnarray*}\downarrow \end{eqnarray*}
\textit{Tridosha Prakopa }(aggravation) 
\begin{eqnarray*}\downarrow \end{eqnarray*}
\textit{Twaka, Rakta, Mamsa, Lasika (Dushya)}
\begin{eqnarray*}\downarrow \end{eqnarray*}
\textit{Sthanasamshraya }(localization)\textit{\space } in \textit{Twacha}
\begin{eqnarray*}\downarrow \end{eqnarray*}
\textit{Ruksha Pidika}with \textit{Kandu}
\begin{eqnarray*}\downarrow \end{eqnarray*}
\textit{Kitibha Kushta}
    
\section{Materials and Methods}
\textbf{Treatment Plan given}

\textit{Shodhana Chikitsa and Shamana Chikitsa }was given to the patient\textit{.}

\textit{\textbf{Shodhana Chikitsa}} \textbf{\space }

\textit{ShodhanChikitsa }was given with \textit{Vamana Karma } in proper sequence of \textit{Purvakarama, Pradhankarma, Paschytkarma }(Tables~\ref{tw-e129cfe3522a} and~\ref{tw-c748e5300b27}).

\textit{\textbf{Shamana Chikitsa}} \textbf{\space }

\textit{Shamana Chikitsa} given using \textit{Gandhak Rasayan} and \textit{Panchtikta Ghrita} along with \textit{Bahirparimarjan Chikitsa } using S-kin Powder with \textit{Gomutra} (Cow urine) and Shabsoria Oil (Tables~\ref{tw-bae8b47e3bcc} and~\ref{tw-c748e5300b27}).

\textbf{\textit{Paschyat Karma}}

After \textit{Samyaka Vamana Lakshana Dhoompan} was given for 5 minutes by each nostril with Aguru stick \unskip~\citep{1028134:21602242}. Then \textit{Sansarjana Karma} was advised for 5 days in the form of \textit{Peya, Vilrpi, AkrutMudgaYusha, KrutMudgaYusha}, normal diet \unskip~\citep{1028134:21602240}.

\textbf{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~\ref{tw-bf96beeef761}). 


\begingroup
\makeatletter\if@twocolumn\@ifundefined{theposttbl}{\gdef\TwoColDocument{true}\onecolumn\onecolumn}{}\fi\makeatother \setlength\LTcapwidth{\textwidth}
\begin{longtable}{p{\dimexpr.1242\linewidth-2\tabcolsep}p{\dimexpr.2612\linewidth-2\tabcolsep}p{\dimexpr.24540000000000006\linewidth-2\tabcolsep}p{\dimexpr.36919999999999995\linewidth-2\tabcolsep}}
\caption{\boldmath {Table showing drugs used in PurvaKarma, PradhanKarma, Paschyat Karma with ingredients} }
\label{tw-c748e5300b27}
\def\arraystretch{1.1}\\\endfirsthead \hline \noalign{\vskip3pt} \noalign{\textit{Table \thetable\ continued}} \noalign{\vskip3pt} 
\tbltoprule \rowcolor{kwdboxcolor}Sr.no & Drug name & Content & Indication\\
\tblmidrule \endhead \hline \noalign{\vskip3pt} \noalign{\textit{\hfill Continued on next page}} \noalign{\vskip3pt} \endfoot \endlastfoot 
\tbltoprule \rowcolor{kwdboxcolor}Sr.no & Drug name & Content & Indication\\
\tblmidrule 
1  &
  Trikatuchurna  &
  Sunthi  \mbox{}\protect\newline Marich  \mbox{}\protect\newline 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, \mbox{}\protect\newline Raktaprasadak, Kandughna,  \mbox{}\protect\newline 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,  \mbox{}\protect\newline Kushta \\
4  &
  MadanphalYoga  &
  MadanphalChurna  (Randiadumetorm)  \mbox{}\protect\newline VachaChurna  (Acoruscalamus)  \mbox{}\protect\newline Saindhaw (Rock salt)  \mbox{}\protect\newline Honey  \mbox{}\protect\newline Milk  \mbox{}\protect\newline YashtimadhuPhant (Glycyrrhizaglabra) &
  Vamanaopag  \mbox{}\protect\newline Vamanaopag  \mbox{}\protect\newline Abhishyandi, Shodhak  \mbox{}\protect\newline Abhishyandi, Yogavahi  \mbox{}\protect\newline Vamanaopag  \mbox{}\protect\newline 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, \mbox{}\protect\newline Sita -Syrup of suger &
  Antibacterial, Antiviral, Antimicrobial, Anti-inflammatory, Antipruritics \\
6  &
  S-kin powder with Gomutra  &
  Manjistha (Rubiacordifolia)   \mbox{}\protect\newline Amalaki, Haritaki, Bibhitaki, \mbox{}\protect\newline 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,  \mbox{}\protect\newline Antimicrobial, Antifungal,  \mbox{}\protect\newline Antiinflammatory, \\
\tblbottomrule 
\end{longtable}
\endgroup
\makeatletter\@ifundefined{TwoColDocument}{}{\twocolumn}\makeatother 

\begin{table*}[!htbp]
\caption{\boldmath {Table Showing evaluation of Samyak Vamana Lakshana} }
\label{tw-3a685fdc5965}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1263\linewidth-2\tabcolsep}p{\dimexpr.2377\linewidth-2\tabcolsep}p{\dimexpr.23599999999999998\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sr.no.  & ManikiShuddhi (Measurement)  & AntikiShuddhi  \mbox{}\protect\newline (Interpretation)  & VegikiShuddhii  \mbox{}\protect\newline (No. of Vega) & LaingikiShuddhi  \mbox{}\protect\newline  (symptoms)\\
\tblmidrule 
Vamana  &
  Intake-3000  \mbox{}\protect\newline Output-3600  &
  PittantakaVamana  &
  8  &
  No bleeding,  \mbox{}\protect\newline Kaphachadrika present in vomitus \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Table showing grading-PASI} }
\label{tw-bf96beeef761}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.40489999999999995\linewidth-2\tabcolsep}p{\dimexpr.27029999999999998\linewidth-2\tabcolsep}p{\dimexpr.14449999999999996\linewidth-2\tabcolsep}p{\dimexpr.1803\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Plaque characteristic  & Lesion Score  & \multicolumn{2}{p{\dimexpr(.3248\linewidth-2\tabcolsep)}}{\cAlignHack Lower Limb }\\
\rowcolor{kwdboxcolor} &  & \cAlignHack Right  & \cAlignHack  Left \\
\tblmidrule 
Erythema  &
  \multicolumn{1}{p{\dimexpr(.27029999999999998\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{0-None  \mbox{}\protect\newline 1-Slight  \mbox{}\protect\newline 2-Moderate  \mbox{}\protect\newline 3-Severe \mbox{}\protect\newline 4-Very severe }} &
  \cAlignHack 0  &
  \cAlignHack 3 \\
Induration/Thickness  &
   &
  \cAlignHack 0  &
  \cAlignHack 3 \\
Scaling  &
   &
  \cAlignHack 0  &
  \cAlignHack 3 \\
 &
   &
   &
  \\
 &
   &
   &
  \\
\multicolumn{2}{p{\dimexpr(.6752\linewidth-2\tabcolsep)}}{Lesion Score Sum (A) } &
  \cAlignHack 0  &
  \cAlignHack 9 \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Table showing grading according to area involved} }
\label{tw-2ab4677f82aa}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3152\linewidth-2\tabcolsep}p{\dimexpr.21250000000000004\linewidth-2\tabcolsep}p{\dimexpr.1101\linewidth-2\tabcolsep}p{\dimexpr.1622\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Percentage area affected  & Involved Area Score  & Grade  & \multicolumn{2}{p{\dimexpr(.3622\linewidth-2\tabcolsep)}}{\cAlignHack Lower Limb }\\
\rowcolor{kwdboxcolor} &  &  & \cAlignHack Right  & \cAlignHack Left \\
\tblmidrule 
\multicolumn{1}{p{\dimexpr(.3152\linewidth-2\tabcolsep)}}{\multirow{7}{\linewidth}{Area Score (B)  }} &
  \cAlignHack 0\%  &
  0 &
  \multicolumn{1}{p{\dimexpr(.1622\linewidth-2\tabcolsep)}}{\multirow{7}{\linewidth}{\cAlignHack 0 }} &
  \multicolumn{1}{p{\dimexpr(.20\linewidth-2\tabcolsep)}}{\multirow{7}{\linewidth}{\cAlignHack 4 }}\\
 &
  \cAlignHack \textless\ 10\%  &
  1 &
   &
  \\
 &
  \cAlignHack 10 - 29\%  &
  2 &
   &
  \\
 &
  \cAlignHack 30 - 49\%  &
  3 &
   &
  \\
 &
  \cAlignHack 50 - 69\%  &
  4 &
   &
  \\
 &
  \cAlignHack 70 - 89\%  &
  5  &
   &
  \\
 &
  \cAlignHack 90 - 100\%  &
  6 &
   &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Table Showing assessment criteria} }
\label{tw-22dcc24c6761}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.29499999999999996\linewidth-2\tabcolsep}p{\dimexpr.23650000000000002\linewidth-2\tabcolsep}p{\dimexpr.2792\linewidth-2\tabcolsep}p{\dimexpr.1893\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} & Left Leg  & Left Leg  & Left Leg\\
\rowcolor{kwdboxcolor} & Before treatment  & After 15 Days & After 30 Days \\
\tblmidrule 
Skin area involved  \mbox{}\protect\newline Grade - A  &
  4  &
  3 &
  0 \\
Erythema  \mbox{}\protect\newline  (redness)  &
  3 &
  2 &
  0\\
Induration \mbox{}\protect\newline (thickness)  &
  3 &
  2 &
  0\\
Desquamation \mbox{}\protect\newline (scaling)  \mbox{}\protect\newline 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 \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Table showing evaluation of Subjective parameters} }
\label{tw-6abf1e3c8fc0}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1191\linewidth-2\tabcolsep}p{\dimexpr.2593\linewidth-2\tabcolsep}p{\dimexpr.218\linewidth-2\tabcolsep}p{\dimexpr.19280000000000005\linewidth-2\tabcolsep}p{\dimexpr.2108\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sr.No. & Sign and Symptoms & Before treatment & After 15 days & After treatment\\
\tblmidrule 
1 &
  Erythema &
  +++ &
  ++ &
  -\\
2 &
  In-duration &
  +++ &
  ++ &
  -\\
3 &
  Desquamation &
  +++ &
  ++ &
  -\\
4 &
  Itching &
  ++++ &
  ++ &
  No Itching\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\bgroup
\fixFloatSize{images/f8e6b666-dd08-4e34-93c7-61e0c3a58cf0-upicture2.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/f8e6b666-dd08-4e34-93c7-61e0c3a58cf0-upicture2.png}{\includegraphics{images/f8e6b666-dd08-4e34-93c7-61e0c3a58cf0-upicture2.png}}{}
\makeatother 
\caption{\boldmath {Showing effect of combination of Ayurvedic modalities on KitibhaKushtha}}
\label{f-6ccd401268c1}
\end{figure}
\egroup
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~\ref{tw-22dcc24c6761}). The percent of skin area involved is evaluated and then converted into a grade from 0 to 6 for each section (Table~\ref{tw-2ab4677f82aa}) \unskip~\citep{1028134:21602234}. 
    
\section{Discussion  }
\textit{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 \textit{Shodhana}, \textit{Shaman} and \textit{Rasayana} Chikitsa \unskip~\citep{1028134:21602236}. 

Patient had an habit of irregular food intake and other \textit{Nidanas} like \textit{MadyaSevana}, \textit{MamsaSevana}, \textit{AdhikaVyayama}, \textit{Ratrijagarana}, \textit{AdhikaChinta} leads to \textit{KitibhaKushta}. \textit{Chikitsa} planned depending on the \textit{Lakshans } (Symptoms) and \textit{Nidanas } like \textit{Deepana}, \textit{Pachana}, \textit{Shodhana} with \textit{Vamana } following the sequence of \textit{Purvakarma, Pradhankarma } and \textit{Paschyatkarma} along with \textit{Shamanoushadh}i, \textit{Bahirparimarjan Chikitsa} (external application) were given. All this equally help to reduce sign and symptoms of \textit{KitibhaKushta} (Table~\ref{tw-6abf1e3c8fc0}  \& Figure~\ref{f-6ccd401268c1}) 

\textbf{Probable Mode of Action of Shodhan (\textit{Vamanakarma)}}

In \textit{Purvakarma Dipana- Pachana } (Appetizer-digestant) was given with \textit{Trikatu Churna}for 3 days which\textit{\space } mainly acts as an Agni Vardhaka, Amadosha Nashaka \unskip~\citep{1028134:21602237}. \textit{AbyantarSnehapana } (Internal oleation) \textit{was given } in increasing order with \textit{PanchatiktaGhrita}for 1 week which pacify \textit{VataDosha. } It subside \textit{Kharata } (Dry scaling), \textit{Parushata}as well as Shyawa Varna in KitibhaKushta \unskip~\citep{1028134:21602232}.\ensuremath{^{}} \textit{MarichyadiTail} was used for \textit{Sarvanga Abhyanga. } It is \textit{Raktashodhaka}, \textit{Vranaropaka, Twachya}mainly reduces dryness and provides hydration to skin and improves the blood circulation \unskip~\citep{1028134:21602238}. 

After \textit{SarwangaSnehana, SarwangaSwedana} given in the form of \textit{NadiSwedan}\unskip~\citep{1028134:21602233}. It removes \textit{Srotasa}ob struction. Due to \textit{Swedana}, \textit{Doshas } gets liquifies and came from \textit{Shakha} to \textit{Koshta} for easy elimination with the help of \textit{Shodhana.}

In \textit{Pradhan Karma Vaman} was given (Table~\ref{tw-3a685fdc5965}) with Madanphal Yoga \unskip~\citep{1028134:21602239}. Followed by \textit{SamsarjanKarma}. For diseases of \textit{KaphaDoshaVaman}a is useful as it given in Samhitas. Due to predominance of \textit{KaphaDosha} in \textit{KitibhaKushta, Vamana} was given. \textit{Vamana} purifies body through there peutice mesis, increase \textit{Agni, } prevents relapsing nature of disease by strengthening Immune system of body. \textit{SamsarjanaKrama}works on \textit{Agni Dipana}. 

After \textit{Vamana} procedure \textit{VataPrako }occurs\textit{,} so for \textit{Vata Shamana Panchatikta Ghrita was }given as \textit{Abhyanter Snehapana } which is indicated in \textit{Kushta. Kushta Roga}came under\textit{Raktapradoshaj Vikar}a cording to Acharya Charaka. \textit{Vasa, Nimba, Patola } and \textit{Guduchi } brakes pathogenesis of \textit{Kushta, } due to potent hepatoprotective action.

\textbf{Mode of action of \textit{Gandhaka Rasayana}}

Gandhaka Rasayana \unskip~\citep{1028134:21602246}  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. \textit{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.

\textbf{Mode of action of \textit{Panchatikta Ghrita}}

\textit{Panchatikta Ghrita} is explained in Bhaishajyaratnavali, In \textit{Kushtadhyaya\textbf{. }} Ingredients of it having \textit{Kushtaghna } property. Go\textit{ghrita}is \textit{Vata-pitta Shamaka}, \textit{Twachya}, useful in healing and has a ``\textit{Samskarasya Anuvartanam'' } property (without losing own property, assimilates the properties of other substance with which it is processed). So \textit{Panchtikta Ghrita} becomes more effective in psoriasis. 

\textbf{Mode of action of S-kin powder with \textit{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 \textit{Raktashodhaka}, \textit{Vranaropaka}, \textit{Twachya} reduces \textit{Kandu}. When the paste of powder made with gomutra applied on skin get penetrated through skin layer. \textit{Gomutra} is strong, piercing, alkaline, astringent\textit{, Vatakaphashamaka} used for treatment of skin disease.\textbf{\space }

\textbf{Mode of action of Shabsoria Oil}

Shabsoria oil useful in skin diseases like psoriasis, itching, eczema due to it's \textit{Kushtaghna} property. Ingredients of Shabsoria oil pacify \textit{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 \textit{Shodhana} (\textit{Vaman}), \textit{Shamana} (Internal medications) and \textit{Bahirparimarjan Chikitsa} patient got relief in his symptoms.
    
\section{Conclusion}
In \textit{Kushta Chikitsa } both \textit{Shodhana } and \textit{Shamana } therapy plays very important role. Symptoms of Plaque psoriasis is similar with \textit{Kitibha Kushta. } This case study concluded that \textit{Kitibha Kushta } can be cured with \textit{Vaman Karma } followed by \textit{Shamana Chikitsa} using internally \textit{Gandhaka Rasayana}, \textit{Panchatikta Ghrita} and externally application of Shabsoria oil, S-kin powder with \textit{Gomutra} for 15 days. By combination of Ayurvedic Modalities like \textit{Shodhana Chikitsa} with \textit{Shaman Chikitsa } (along with \textit{Bahirparimarjan Chikitsa}) better results can be achieved. 
    
\section{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. 

\textbf{Funding Support}

The authors declare that they have no funding support for this study.

\textbf{Conflict of Interest}

The authors declare that there is no conflict of interest for this study.
    

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